Workout Form
Thursday, November 29, 2007

Please fill out this form as accurately as you can to ensure a workout that will provide you with the greatest benefit.

Note: Information contained on this form will not be redistributed to any other person or organization!

Personal
First Name Last Name Age E-mail Address
Medical History

Medical
Check all of the following for which you (P) or a blood relative (F) has been diagnosed or treated by a health professional:
Alergies F P
Anemia F P
Asthma F P
Bleeding Trait (Hemophilia) F P
Cardiovascular Disease F P
Coronary Disease F P
Diabetes Mellitus F P
Epilepsy F P
Heart Problems:
Valve F P
Murmur F P
Palpitations F P
Heart Attack F P
Hernia F P
High Colesterol F P
Hypertension F P
Neurologic Disease F P
Obesity F P
Phlebitis F P
Rheumatic Fever F P
Ulcer F P
Varicose Veins F P
Surgery:
Musculoskelatal Present Conditions
Are you aware of any of the following?
Bursitis F P
Back Injury F P
Cartilage Tear F P
Knee Problems F P
Joint Dislocation F P
Ligament/Tendon Injury F P
Rheumatoid Arthritis F P
Spinal Disc Problems F P
Spinal Alignment F P
Other:
Back Pain Yes No
Blurr Vision Yes No
Chest Pain Yes No
Chronic Nose Bleeds Yes No
Cough on Exertion Yes No
Dizziness Yes No
Leg Cramps Yes No
Migraine Headaches Yes No
Shortness of Breath Yes No
Weakness Yes No
General
Height & Weight Medication
Height
Frame
Now: lbs.
One year ago: lbs.
At age 21: lbs.
Are you taking any? Yes No
If yes, which?
Smoking
Do you Smoke? Yes No
How many/day? Cigarettes
Exercise Diet
Which describes your exercise?
Light Moderate Heavy
Describe:
Are you dieting? Yes No
Describe:
Women
Are you pregnant? Yes No If yes, how many months?
Activities
Check all of the following for which you are training:
Sport(s) Personal
Baseball/Softball
Football
Basketball
Golf
Boxing
Wrestling
Swimming
Roller/Ice Hockey
Other:
Police Exam
Fireman Exam
FBI Exam
Wedding
Dating
General Personal Appearance
General Health
Other:

 

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