Gender: Male Female

Have you had or do you have:

Heart Attack Thrombophlebitis Rapid Heart Beat

Angina Asthma Anemia High Blood Pressure

Abnormal Electrocardiogram Fixed Rate Pacemaker

Low Blood Pressure Heart Medications Embolism

Diabetes Valve Disease Respiratory Infections

Epilepsy Aneurysm Irregular Heart Beats

Has your physician advised you against exercise?

Yes No

If YES, why and when?

Do you have any of the following conditions?

Arthritis Ankle/Foot Injury Shoulder Clavicle Injury

Low Back Pain Arm/Elbow Injury Knee/Thigh Injury

Calcium Deposits Nerve Damage Upper Back Injury

Head/Neck Injury Bone Fracture Wrist/Hand Injury

Hip/Pelvis Injury Tennis Elbow

If you checked any of the items above please explain.

Are you currently receiving physical therapy?

Yes No

If YES, what is your therapist's name and phone number?

May we call him/her?

Yes No

Do you smoke?

Yes No

If YES, how often and for how long?

Do you have any past injuries that limit the range of motion of your muscles,
joints, bones, spinal column, or any other part of your body which may be
aggravated by exercise?


Yes No

If YES, explain.

Are you taking any medications on a regular basis?

Yes No

If YES, list names and dosage.

Are you currently under a doctor's care?

Yes No

If YES, name and phone number of doctor.

Are you currently on a specific diet?

Yes No

If YES, please describe.

Are you tired or fatigued most of the day?

Yes No

Are you tired or fatigued at a specific time of day?

Yes No

If YES, when?

How would you rate the amount of physical activity you perform while at work?

Very Little Little Moderate Active Very Active

How would you rate the amount of physical activity you perform during leisure time?

Very Little Little Moderate Active Very Active

Are you presently in any physical fitness program?

Yes No

If YES, please explain in detail.

How physically fit do you feel presently?

Unfit Below Average Average Above Average Very Fit

Do you have exercise equipment at home?

Yes No

If YES, describe.

Did you particiapte in high school or college athletics?

Yes No

If YES, describe.

Please specify any activities which would not interest you or cause you pain or discomfort.

Briefly describe your exercise history.

What are your primary reasons for consulting with Personal Fitness?

General Conditioning Weight Loss Muscular Strength

Stress Reduction Flexibility Cardiovascular Conditioning

Other, please specify

Other concerns and comments.

How did you hear about PFP?

LEAVE THESE FIELDS BLANK, YOU WILL SIGN THIS FORM WHEN YOU COME IN FOR YOUR FIRST APPOINTMENT.