Physical activity readiness questionnaireIn order to assist you in the development of a rewarding physical fitness program, please answer the following questions honestly and accurately. Name * First Name Last Name Email * Sex * Male Female Today's Date * MM DD YYYY Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * First Name Last Name Emergency Contact's Phone * (###) ### #### Relationship To You * Physician's Name * First Name Last Name Physician's Phone * (###) ### #### Has a physician ever advised you against exercise? * Yes No Has a physician ever told you that you have heart trouble? * Yes No Do you frequently have pains in your chest or heart? * Yes No Do you often feel faint or severe dizziness? * Yes No Has a physician ever told you that your blood pressure was too high? * Yes No Has a physician ever told you that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse by exercise? * Yes No Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to? * Yes No Are you over the age of 65 and not accustomed to vigorous exercise? * Yes No If you answered Yes to one or more of the above questions, you must consult with your physician BEFORE increasing your physical activity Please check if you have a history of the following: * Heart Attack or any type of heart condition Bypass or cardiac surgery Chest discomfort with exertion High blood pressure Rapid or runaway heartbeat Skipped heartbeat Rheumatic fever Phlebitis or embolism Shortness of breath w/or w/o exercise Fainting or light-headedness Pulmonary disease or disorder High blood fat (lipid) level Stroke Recent hospitalization Orthopedic problems (including arthritis) None of the above For any condition checked above, please list the diagnosis and examining physician: Explain any health problems or injuries not listed above, medications you take (including dosages) and any therapies you are currently undertaking: Please check the box that best describes your personal family history (blood relatives only): * No known history of heart disease One relative over age 60 with CV disease Two relatives over age 60 with CV disease One relative under age 60 with CV disease Two relatives under age 60 with CV disease Three relatives under age 60 with CV disease Regarding smoking, please check the box that best describes your current habits: * Nonuser or former user Cigar and/or pipe 15 or fewer cigarettes per day 16-25 cigarettes per day 26-35 cigarettes per day More than 36 cigarettes per day If former user, when did you quit? Please check the box that best describes your work and exercise habits: * Intense occupational and recreational exertion Moderate occupational and recreational exertion Sedentary work and intense recreational exertion Sedentary work and moderate recreational exertion Sedentary work and light recreational exertion Complete lack of all exertion I give my consent to participate in the physical fitness program conducted by Jason Miller. * I agree to the following terms and conditions of this Personal Training Agreement: I understand that any/all recommended exercises are voluntary and I can refuse to participate in any/all of the recommended exercises. This form was verbally explained to me and I have read and understand the terms and conditions of this agreement. I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardiorespiratory system (dizziness, discomfort in breathing, heart attack). I hereby certify that I know of no medical problem (except those noted above) that would increase my risk of illness and injury as a result of participation in a regular exercise program. I am not aware of any disease or disorder that would complicate my participation in a testing or exercise program, other than the medical conditions I have checked above. Thank you!
