Name Gender: Male Female

Date:

Date of Birth:

Address: (work)

Address: (home)

Telephone (home)

Telephone (work)

Email Address

Where did you hear about Competitive Advantage?

In what type of business or industry do you work?

*Before starting any type of physical conditioning program it is always best to have a complete physical exam,
which includes a stress test. Only after your doctor has given you clearance to exercise, should you begin any
type of conditioning program that involves vigorous or strenuous exercise.

Please read and sign below:

I hereby understand that I will be participating in a personal fitness training program provided by Competitive Advantage. I understand that Competitive Advantage is unaware of my physical condition upon commencement of the training program. I realize that it is my responsibility to determine that I am capable of undergoing strenuous physical activity. Because the effects of the program depend in part upon the efforts of the individual, results may vary from person to person. Competitive Advantage makes no warranties, guaranties, or claims expressed or implied, regarding the extent of the benefits that any individual may derive from the program. I understand that the nature and purpose of the program requires me to engage in strenuous physical activity and I am aware that any strenuous activity involves risks. I hereby assume the risk of any and all accidents or injuries of any kind which may be sustained by me by reason of or in connection with my participation in the program. I hereby release, discharge and absolve Competitive Advantage, its agents and employees from any and all liability or responsibility for any such accident or injury except to the extent such accident or injury is caused by or result from gross negligence or willful misconduct of Competitive Advantage, its agents or its employees.

Print Name:

 

Please answer the following questions as best as possible. If it is determined that you have a moderate or higher risk factor profile for developing coronary heart disease and your doctor has not given you approval to exercise in the past six months, Competitive Advantage strongly suggests you contact your physician as soon as possible for exercise approval.

 

1. Have you ever been told by a physician that you have heart disease? If so please explain. Yes    No

2. Have you ever had any heart problems, i.e. heart attacks, coronary occlusion, aortic aneurysm,
myocardial infarction, coronary insufficiency, coronary thrombosis, arrhythmia, angina, cardiomyopathy,
or a mitral value prolapse? If so please explain. Yes    No

3.Have you ever undergone cardiac surgery? If so please explain. Yes     No

4. Have you ever experienced sharp pain, tightness or heavy pressure in your chest, neck, shoulders
or arms during or after exercise or physical activity? If so please explain. Yes   No

5. Do you have any pulmonary disease? If so please explain. Yes   No

6. Do you have any cerebrovascular problems, i.e. stroke? If so please explain. Yes   No

7. Do you have any peripheral vascular problems, i.e. phlebitis, arteriosclerosis, aneurysm, gout?
If so please explain. Yes   No

8. Have you ever had rheumatic fever? If so please explain. Yes   No

9. Have you ever had any type of cancer? If so please explain. Yes   No

10. Do you have any emotional disorders? If so please explain. Yes   No

11. Do you have any eating disorders? If so please explain. Yes   No

12. Do you have iron deficient or aplastic anemia? If so please explain. Yes   No

13. Do you have any allergies? If so please explain. Yes   No

14. Do you have any other medical problems? If so please explain. Yes   No

15. Have you ever had a stress test? If so please explain. Yes   No

16. Have you ever had a stress test? If so please explain the reason and date of the test. Yes   No

17. When was the last time you had a complete physical?

18. Have you had any surgical procedures within the last year? If so please explain. Yes   No

19. Have you had any surgical procedures within the last year? If so please explain the nature
of the procedure. Yes   No

20. Do you have any type of physical condition, impairment, or disability that should be considered
before you begin an exercise program? If so please explain. Yes   No

21. Has your doctor informed you of anything that would be contraindicated when participating in
a physical conditioning program? If so please explain. Yes   No

22. Do you take any prescription medication? If so please explain. Yes   No

23. Are you allergic to any medication? If so please explain. Yes   No

Female Related Questions:

24. Are you post menopausal? Yes   No

25. If you are, do you take any type of estrogen replacement therapy? Yes   No

26. Are you currently pregnant? Yes   No

27. If you are, how long have you been pregnant?

28. Have you given birth within the last six months? Yes   No

29. If you have, when did you give birth?

30. Do you have hypertension (high blood pressure)? Yes   No

31. Do you have diabetes? Yes   No

32. Do you have high cholesterol or high triglycerides? Yes   No

33. Did your father or mother(s) die from heart disease before age 55? Yes   No

34. Did your mother or sister (s) die from heart disease before age 65? Yes   No

35. Do you smoke? Yes   No

36. Does your work involve any physical activity? If so please explain. Yes   No

37. How much physical activity do you engage in during your leisure time?

38. If you do exercise, what types of activities do you do?

End of Female Related Questions.

39. Do you have osteoporosis? Yes   No

40. Do you have arthritis? Yes   No

41. Do you have any injuries (ligament, tendon, or muscular) other orthopedic problems?
(if yes, explain nature and severity) Yes   No

42. Have you ever broken any bones? Yes   No

43. Do you have any injuries that have required physical therapy? Yes   No

44. Do you consume alcohol? (if yes, what types and how much ?) Yes   No

45. Do you drink coffee? Yes   No  (if yes how much?)

46. Do you consider yourself overweight? Yes   No

47. Have you ever been advised by a physician, nutritionist, or dietitian regarding your diet? Yes   No

48. Would you like assistance in planning and following a balanced nutritional program? Yes   No

49. How many hours a night do you sleep?

50. Do you have trouble sleeping? Yes   No

51. Describe your stress level.

FITNESS BACKGROUND

52. Do you have a background in athletics or weight training? (if so, what?) Yes   No

53. Are you currently active? Yes   No

54. What sports, activities, hobbies do you partake in?

55. Any exercise dislikes?

56. Do you use a home gym or are you a member of a health club? If you are a member
of a health club, which one? Yes   No

57. What are your personal fitness goals?




59. On a scale of 1-10 how would you rate your level of intensity during your workout?
(1 being the lowest and 10 being the highest)

60. Current Exercise Schedule:

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Sunday:

61. List your weight at the following ages:

Teens:   20:   30:   40:   50:   60:   70:

62. Describe the types of food you normally eat and teh time of day when you eat your food.

Breakfast: Time/Type of food

Lunch: Time/Type of food

Dinner: Time/Type of food

63: How much time are you willing to put into this fitness program?

64: Describe in your own words, what are your fitness goals, when you would realistically like to reach these goals and trouble areas for yourself.