Personal Data Profile
Last Name:   First Name:   Email:   Confirm Email:   Sex:   Male Female			Date of Birth :   Age:   Height:   Weight:
Enter the word AGREE if you have read the Waiver form and agree to all terms:
Review of Medical History
It is important to inform us of any past or present medical problems. Be assured that this information is taken in strict confidentiality.
Personal Medical History:
Have you ever been diagnosed with any of the following? (check all that apply):
Cardiovascular disease (including myocardial infraction)
Hypertension       Diabetes       Obesity       Asthma       Emphysema       Bronchitis       Stroke		High cholesterol       Cancer       Osteoporosis       Emotional disorders       Eating disorders       Musculoskeletal disorders
If any of the above are checked please list and describe treatment:
Other Significant Past Illness/Treatment:
List all surgeries and their dates:
Are you currently taking antibiotics?
	NoYes,  if yes please explain:
Are you currently taking anti-inflamatories, prescription or non-prescription? (i.e. Advil)
	NoYes,  if yes please explain:
List all other medication and supplements:
List allergies to medication:
Do you, or did you ever experience unusual shortness of breath, chest pain, palpitations Tachycardia (unusual rapid heart rate) or dizziness? NoYes
Please explain any orthopedic problems (arthritis, bursitis, stress fractures, broken bones, hip or knee replacements, low back pain, knee problems, etc.):
Have you ever had a stress test? NoYes  if yes please explain why and when:
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History of Symptoms:
Have you ever had discomfort (pressure, tingling, pain, heaviness, burning, tightness, squeezing, numbness,) in the chest, jaw, neck, back, or arms? NoYes
Have you ever experienced light-headedness, dizziness, or fainting? NoYes
Have you ever experienced a temporary loss of vision or speech or a transient numbness on one side of your body? NoYes
Have you ever experienced unusual shortness of breath, rapid heartbeats or palpitations, especially if associated with physical activity, eating a large meal, emotional upset, or exposure to cold or any combination of these activities? NoYes
Do you have sleeping problems? NoYes
Do you have a consistently high heart rate? NoYes
Have a numbness? NoYes
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Life Style Information:
Has your weight changed in the last year?   Please Select No change in weight Increased weight Decreased weight by number of pounds:
Do you consider yourself underweight? NoYes
Do you consider yourself overweight?   NoYes
Are you on a diet now? NoYes,  if yes please explain:
Smoking History:
Never smoke
Quit smoking, approximate date:
Currently smoking cigarettes PER DAY
Smoke cigar or pipe PER DAY
Caffeine Intake? PER DAY:
cups of regular coffee			cups of regular tea
cans of cola			bottles of regular iced tea
cups of hot chocolate			chocolate bars
Estimate the number of alcoholic beverages consumed PER WEEK
bottles of beer     glasses of wine     mixed drinks
How many meals do you eat PER DAY? (1-8)
Do you usually eat breakfast?   NoYes
Please describe a typical day of eating. List all food and drink intake, this includes candy, gum, mints, etc.
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Physical Activity Information
Are you currently involved in any fitness?   NoYes
Which would best describe your type of fitness activity?
VERY LITTLE EFFORT: (Bowling, archery, very slow walking, golf with a cart) LIGHT EFFORT: (Golf, pulling cart, swimming slowly, walking 2-3 mph, bicycling 5-7 mph, social dancing) MODERATE EFFORT: (Golf, carrying clubs, swimming-25 yds/min, social tennis, moderate aerobic dance, walking 4 mph, bicycling 8-11 mph) VIGOROUS EFFORT: (Running 5-6 mph, bicycling, faster then 11 mph, vigorous aerobic dance, swimming 50 yds/min, social basketball, rowing) EXTREMELY VIGOROUS EFFORT: (Running 7+ mph competitive sports, singles tennis, racquetball, cross country skiing, other high heart rate activities)
How frequently do you participate in cardiovascular exercise (running, walking, cycling, swimming, rowing. ect.)?
Not at all Less then once per week 1-2 times per week 3-4 times per week Greater than 4 times per week
When you exercise, how long is each session?
Up to 10 minutes 10-20 minutes 20-30 minutes 30+ minutes
Are you presently involved in any weight training activities?   NoYes
If yes, what and how often:
What type of work do you do?
What are the physical demands of your job?
Upper body:
Lower body:
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Personal goals: (List desires improvements, i.e. strength, size, speed, losing/gaining weight).
1.
2.
3.
Involvement in Sports Recreational Activities:
1.
2.
3.
Activity Schedule: (Best days to train)
Monday  Tuesday  Wednesday  Thursday  Friday  Saturday
*Workout will be designed within 24 hours of submitting profile. All information is confidential and will never be sold as a list or used for any purpose other than specified.