"Live a DRUG - FREE Life"

 

Please complete the following questionaire.

   

Personal Information
Name :
Street Address :
City, State, ZIP:
Phone:
Email Address :
Date of Birth:

 

Body Measurements (You may need somebody to assist.)

 
Height:
Weight:
Body Fat %:
Shoulders:
Chest:
Waist:
Hips:
Arms:
Thighs:
Calves:
Resting Pulse :

 

Medical History

 
Have you consulted with your doctor about a physical fitness program?
Yes
No
Have you felt any pain in your chest in the past month?
Yes
No
Do you feel pain in your chest while doing any physical activity?
Yes
No
Do you feel any joint or bone problems that can be affected by a change in your physical activity?
Yes
No
Are you taking any prescription drugs?
Yes
No

If YES, please list them and describe the reason for their use.

 
Do you know of any other reasons why you should not be doing any physical activity?
Yes
No
Please check any of the following conditions that apply to you:
   
Heart Condition Cervical Problems Arthritis
Rheumatism Wrist Problems Sacroiliac Problem
Back Problems Diabetes Lumbar Problems
Knee Problems Angina Hip Problems
Asthma Thoracic Problems Bursitis
Hernia Ankle Problems Recent Surgery
High Blood Pressure Elbow Problems  
Other: Please Describe

 

Current Fitness Level

 
Have you ever done any weight training before?
Yes
No
Are you currently on a weight training program?
Yes
No

If YES, how long have you been on the program?

 
When was the last time you worked out with weights?
Are you currently exercising at:
(i.e. a gym, home, work, etc.)

 

Weight Training

 
How many days per week do you exercise?
How many hours per day do you exercise?

 

Cardiovascular Training

 
How many days per week do you do cardiovascular exercise?
How many hours a day do you do cardio?
How would you rate yourself on exercising?
(i.e. beginner, intermediate, advanced)
 

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