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Answer Each Question by Printing the Necessary Information. Your Answers are Confidential

MEDICAL INFORMATION _______________________________________________________________________

Are you under the care of a physician, chiropractor, or other health care professionals for any reason? if yes, list reasons:
Are you taking any medications? (if yes, complete the following- type, dosage/frequency, reason for taking):
Has your doctor said your blood pressure was too high?
Are you over the age of 65?
Is there any reason not mentioned why you should not follow a regular exercise program? If yes, please explain?
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?
Are you unaccustomed to vigrous exercise?
Have you recently experienced any chest pain associated with either exercise or stress? If yes, please explain

FAMILY/ PERSONAL MEDICAL HISTORY _______________________________________________________

If there is family history for any condition, please check the box to the left. If you are personally experiencing any of these conditions, fill the information in on the line to the below.
Occupational stress level:

LIFESTYLE AND DIETARY FACTORS ____________________________

Energy level:

CARDIOVASCULAR _____________________________________________

MUSCULOSKELETAL INFORMATION ______________________________

Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain, or general discomfort: If none put none or N/A

Are you on any specific food/diet plan at this time?

NUTRITIONAL INFORMATION ____________________________________________________________________

Do you take dietary supplements?
Have you experienced a recent weight gain or loss?
Do you experience any frequent weight fluctuations?
How many beverages do you consume per day that contain caffeine?
Other food/nutritional issues you want to include (food allergies, mealtimes, etc.)
How would you describe your current nutritional habits?

WORK AND EXERCISE HABITS ___________________________________________________________________

Please check the box that best describes your work and exercise Habits.
Do you work more than 40 hours a week?
To what degree do you perceive your WORK environment as stressful?
To what degree do you perceive your HOME environment as stressful?
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