Physical Fitness Form - Toronto's Best Health Club - Sport Medicine, Fitness, Weights, Personal Training, Physio and Classes!

First Name

First

Last Name

Last

Date of Birth

Today's Date

Please choose your home club

Email

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

YES

NO

Do you feel pain in your chest when you do physical activity? *

YES

NO

In the past month, have you had chest pain when you were not doing physical activity? *

YES

NO

Do you lose your balance because of dizziness or do you ever lose consciousness? *

YES

NO

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? *

YES

NO

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

YES

NO

Do you know of any other reason why you should not do physical activity? *

YES

NO

Fitness Background - History

Are you presently exercising?

IF YES: Type of exercise:

Frequency:

Duration:

Since:

IF NO: How long have you been thinking of starting an exercise programme?

What recreational activities do you participate in?

Are you happy with your present physical state?

When were you most satisfied physically?

What is your current weight?

What is your desired weight?

What do you like/dislike about your physique?

Lifestyle Habits - Behavior

Occupation

Company

Description of work performed

Hours worked in one week

Days worked in one week

Do you smoke?

Have you ever smoked?

If yes, for how long?

Do you drink alcohol?

How many drinks per week

Do you drink coffee?

How many cups per day?

Sleep pattern

How many hours per night?

On a scale of 1- 10, how would you rate your Nutrition

(1= poor, 10=excellent)

List any allergies, sensitivities, supplements and medications you have now or in the past.

Medical Background

Bone or joint problems:

Recent surgery:

Previous injuries:

Are you accustomed to vigorous exercise?

Are you presently taking any medication or supplements?

If YES please specify:

Is there a physical reason not mentioned why you should not follow a program?

If YES please specify:

Goals

Please list in order of priority 3 fitness – based goals you would like to achieve:

Fitness Goal #1

Fitness Goal #2

Fitness Goal #3

Is there any appropriate deadline for these goals?

If yes when?

On a scale of 1 to 10 how important is achieving these goals to you?

1 = low, 10 = extremely important

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