Fitness Goals and History                 

To prepare  an optimum program, we at     Focused On Fitness need to know a little about you. Please complete and print the information below and bring it to your first appointment. All information will, of course, remain confidential.


Date: Referred by:
Name: Height: Weight:
Occupation: Sex: M F Age:
Address: Birth Date:
Address Continued:
City: State: Zip:
Email Address:
Day Phone: Evening Phone:
Physician's Name: Phone:
Presently taking medication? Y: N:
If yes, for what condition(s)?

What regular physical activity do you currently participate in?

What physical activities did you participate in school or college?

What are your fitness goals?

Now or within the past year have you had any of the following:

ConditionYesNo
I've had Heart problems
Family History of heart problems
High blood pressure (hypertension)
Difficulty with physical exertion
Do you smoke?
Elevated cholesterol levels
A chronic illness
Advice from a physician not to exercise
Recent surgery
History of lung problems
Diabetes?
Obesity (more than 20 lbs. overweight)?
Any muscle, joint back or other disorder, which could potentially be aggravated by physical activity?

What are your sleeping habits and position?

Diet -- What do you typically have for:
Breakfast
Lunch
Dinner
Snack