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:
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? Reduce body fat Improve cardiovascular endurance Gain lean muscle mass Tone and shape Compete in an athletic event Event preparation (i.e. wedding, reunion, tryout, fitness competition) 58. How long does your typical workout last? 30 min 30-60 min 1-1.5 hrs 1.5 - 2 hrs over 2 hrs
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.