| *How did you FIRST learn about Sensible Fitness?
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| *Your Name: |
| *E-mail Address: |
| *Address: |
| *City/State/Zip / / |
| *Phone Home: |
| Work: |
| Mobile: |
| *Height (in INCHES): |
| *Weight: |
| *Date of Birth: |
| *Gender:
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| *Profession: |
*Does your profession involve sitting for a large part of the day?
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*Emergency Contact:
Phone:
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*What are your specific goals? (i.e. weight loss, gain muscle, toning lower body, etc.)
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For general scheduling purposes only (no commitment), what days and times are best for you to visit us? The more specific you can be the easier to match you with a trainer. (i.e. Monday's at 6 p.m. or after, Wednesday mornings before 10 a.m., Saturday's anytime, etc.)
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For general scheduling purposes only (no commitment), how often do you wish to visit us? (i.e. 3 times per week for several months, only a few visits, once every two weeks for 4 months, etc.)
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*How many times per week do you currently exercise?
days |
| *How would you describe the intensity of this exercise?
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| *How long have you been exercising?
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| *What is the duration of a typical session?
minutes |
*What types of exercise do you perform?
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| *What level of exercise do you wish to perform with us?
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*Do you currently smoke?
If yes how many per day? |
| *Have you quit smoking in the last 2 years?
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| *Do you often have pains in your heart, chest, or surrounding areas, especially during exercise?
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| *Do you often feel faint or have spells of severe dizziness during exercise?
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| *Do you experience unusual fatigue or shortness of breath at rest of with mild exhertion?
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| *Have you had an attack of shortness of breath that came on after you had stopped exercising?
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| *Have you been awakened at night by an attack of shortness of breath?
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| *Do you experience swelling or accumulation of fluid in and around the ankles?
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| *Do you often get the feeling that your heart is racing or skipping beats, either at rest or during exercise
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| *Do you regularly get pains in your calves or lower legs that are not due to soreness or stiffness?
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*List any diseases (including high blood pressure) that a doctor has told you that you have (Enter NONE if you have no known diseases):
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*Have you ever been told that you have diabetes?
If Yes, what type:
How long have you had it:
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*List any medications that you take on a regular basis (Enter NONE if you take no medications):
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*Has your father, mother, brother, or sister had a heart attack, or suffered, or died from cardiovascular disease before the age of 65?
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a. If yes, was it a male or female relative?
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b. How old were they when they were diagnosed? |
| « QUESTIONS 39 & 40 WOMEN ONLY » |
| Is it possible that you are pregnant?
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| Have you experienced menopause before the age of 45?
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a. If yes, are you currently taking hormone replacement therapy?
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