Consultation Form Name * First Name Last Name Email * Phone (###) ### #### Physicians Name Physicians Phone # (###) ### #### Person to Contact in Case of Emergency: First Name Last Name Phone# (###) ### #### Are you taking any medications, supplements, or drugs? If so, please list medication, dose, and reason. Does your Physician know you are participating in this exercise program? Yes No Describe any physical activity you do somewhat regularly. Do you have, or have you had in the past any of the following: (Check all that apply) History of heart problems, chest pain, or stroke Elevated blood pressure Any chronic illness or condition Difficulty with physical exercise Advice from Physician not to exercise Recent surgery (last 12 months) Pregnancy (now or within last 3 months) History of breathing or lung problems Muscle, joint, or back disorder, or any previous injury still affecting you Diabetes or metabolic syndrome Thyroid condition Cigarette smoking habit Obesity (BMI greater than 30kg) Elevated blood cholesterol History of heart problems in immediate family Hernia, or any condition that may be aggravated by lifting weights, or other physical activity Please rate your exercise level on a scale of 1 to 5 (5 indicating very strenuous) for each age range through your present age: Age 15-20 1 2 3 4 5 Age 21-30 1 2 3 4 5 Age 31-40 1 2 3 4 5 Age 41-50 1 2 3 4 5 Age 51+ 1 2 3 4 5 Were you a high school and/or college athlete? If Yes, please explain Do you have any negative feelings toward, or have you had any bad experience with, physical-activity programs? If Yes, please explain What are your fitness goals? Check all that apply Appearance (aesthetics) Cardiovascular endurance Flexibility Health (General) Muscular definition Muscular size Muscular strength/power Self-esteem or confidence Speed Sports performance Stress reduction Toning and shaping Weight loss Posture Thank you!
