"Fitness Assessment Form - Pg Fit"

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FITNESS ASSESSMENT FORM
PERSONAL INFORMATION
Today’s Date: _______________
Date of Birth: _____________________ Male  Female
Name:_________________________________
Occupation: _____________________________ Email: ___________________________________________
Address:__________________________________________________________________________________
City: _____________________________ State: _______ Zip Code: ________
Day Phone: _________________Evening Phone: __________________Cell Phone______________________
Emergency Contact_______________________ Phone: ________________ Relation:__________________
Dr. Name:_______________________________ Phone: ________________
PHYSICAL ACTIVITY & MEDICAL HISTORY
YES NO YES NO
Has a doctor ever said you have a heart condition and recommended
___ ___
1.
Heart Condition
only medically supervised activity?
___ ___
___ ___
Diabetes
2. Do you have chest pain brought on by physical activity? ___ ___
___ ___
Asthma
3. Do you tend to lose consciousness or fall over a result of dizziness?
___ ___
___ ___
Short of Breath
4. Has a doctor ever recommended medication for your blood pressure
___ ___
Arthritis Bursitis
or a heart condition?
___ ___
___ ___
Rheumatism
5. Do you have a bone or joint problem that could be aggravated by the
___ ___
Hernia
proposed physical activity?
___ ___
___ ___
Recent Surgery
6. Are you aware, through your own experiences or a doctor’s advice,
__ ____
Sacroiliac Problem __
of any other physical reason against your exercising without medical
___ ___
Angina
service?
___ ___
High Blood Pressure____ _____
7. Are you over the age of 65 and not accustom to vigorous exercise?
___ ___
___ ___
Knee Problems
___ ___
Back Problems
If you answered YES to any of the above, please answer the following:
Cervical Thoracic Lumbar
8. Have you
consulted your physician regarding increasing your physical
activity and/or performing a
If “YES” to any of the above
fitness assessment?
___ ___
please see Fitness Manager
9. If you answered NO to question 8, will you consult your physician prior
scheduled.
before exercise is
to increasing your physical activity and performing a fitness assessment?___ ___
I certify that the above statements are true and correct. I understand that a Doctor’s note may be
requested. If a note is requested, I should not proceed with this workout until the note is received.
Member Signature: ____________________________________
Date: _____________________
FITNESS ASSESSMENT FORM
PERSONAL INFORMATION
Today’s Date: _______________
Date of Birth: _____________________ Male  Female
Name:_________________________________
Occupation: _____________________________ Email: ___________________________________________
Address:__________________________________________________________________________________
City: _____________________________ State: _______ Zip Code: ________
Day Phone: _________________Evening Phone: __________________Cell Phone______________________
Emergency Contact_______________________ Phone: ________________ Relation:__________________
Dr. Name:_______________________________ Phone: ________________
PHYSICAL ACTIVITY & MEDICAL HISTORY
YES NO YES NO
Has a doctor ever said you have a heart condition and recommended
___ ___
1.
Heart Condition
only medically supervised activity?
___ ___
___ ___
Diabetes
2. Do you have chest pain brought on by physical activity? ___ ___
___ ___
Asthma
3. Do you tend to lose consciousness or fall over a result of dizziness?
___ ___
___ ___
Short of Breath
4. Has a doctor ever recommended medication for your blood pressure
___ ___
Arthritis Bursitis
or a heart condition?
___ ___
___ ___
Rheumatism
5. Do you have a bone or joint problem that could be aggravated by the
___ ___
Hernia
proposed physical activity?
___ ___
___ ___
Recent Surgery
6. Are you aware, through your own experiences or a doctor’s advice,
__ ____
Sacroiliac Problem __
of any other physical reason against your exercising without medical
___ ___
Angina
service?
___ ___
High Blood Pressure____ _____
7. Are you over the age of 65 and not accustom to vigorous exercise?
___ ___
___ ___
Knee Problems
___ ___
Back Problems
If you answered YES to any of the above, please answer the following:
Cervical Thoracic Lumbar
8. Have you
consulted your physician regarding increasing your physical
activity and/or performing a
If “YES” to any of the above
fitness assessment?
___ ___
please see Fitness Manager
9. If you answered NO to question 8, will you consult your physician prior
scheduled.
before exercise is
to increasing your physical activity and performing a fitness assessment?___ ___
I certify that the above statements are true and correct. I understand that a Doctor’s note may be
requested. If a note is requested, I should not proceed with this workout until the note is received.
Member Signature: ____________________________________
Date: _____________________
EXERCISE / MOVEMENT QUESTIONNAIRE
YES NO
. Are you currently involved in an existing exercise program?
1
YES NO
2. Are you currently involved in a structured resistance training program?
If yes, how long (consistently?)
< 6 months 6 months to 1 year > I year
YES NO
3. Are you currently participating in a structured cardiorespiratory program?
If yes, __________ days/week, ________ minutes per day, using (mode) ________________
4. Other physical activities/interests (including frequency)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
PRE- EXERCISE QUESTIONNAIRE
What is your primary goal? Weight Loss Muscle Gain Sport Performance Improve Health/Daily Activity
1
.
2. Specific desires (lbs. weight loss/gain, sport dynamic, aspect of health, etc….)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
3. Specific reasons (why? why now? time frame?)
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
4. Past attempts in obtaining goal (formal/informal programs, successes, challenges, money spent)
________________________________________________________________________________________________________________________
__________________________________________________________________
5. Goal outcomes (how will you feel when goal is obtained? emotional/physical benefits?)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
6. Level of commitment in accomplishing the goal? (circle) LOW
1
2
3 4 5 6 7 8 9 10
HIGH
7. Support/accountability? (Spouse/significant other) _________________________________________________
8. How much time do you have budgeted? __________________ days/weeks; _____________________hours/day
FOOD/NUTRITION QUESTIONNAIRE
Typically, how many meals do you eat per day? (circle one)
1
2
3
4
5
6
.
1
2. Typically, what time are these meals? ____________________________________________________________
3. Typically, how many calories do you consume per day? _____________________________________________
 YES  NO
4. Do you know how many calories you should be eating to reach/support your goal?
If YES, how many and how was this determined _____________________________________________
5. Are you currently taking a multi-vitamin or any other dietary supplements?  YES  NO
6. How would you describe your diet?  Regular  Lacto-Ovo Vegetarian  Vegan
7. Typically how many meals do you eat outside the home per week? ____________________________________
Would the majority of these meals be described as:  Fast Food (take-out)  Seated Restaurants
8. How would you rate your eating habits? (circle one)
1
2
3
4
5 6
7
8
9 10
VERY POOR
VERY GOOD
Strengths? Weaknesses? ________________________________________________________________________________________________
Additional Comments:_____________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
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