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Personal Fitness Questionnaire

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					                            BODY by RAHEEM
                                  703 Chestnut Avenue
                                    Trenton, NJ 08611
                                     (609) 203-3451
                                 fitnessrah@yahoo.com
       Personal Fitness and Medical History Questionnaire

Contact Information:
Client’s First Name: ________________________________________________
Client’s Last Name: ________________________________________________
Address: ________________________________________________________
City: _____________________________ State: ______ Zip:________________
Home Phone: _____________________ Email: __________________________
Work Phone: ________________________ Cell Phone: ___________________
Emergency Contact: Name and number ________________________________
Gender: Male Female
Age: _____ Height: _____ Weight: _____

Fitness History:
Do you exercise on a regular basis? Yes  No 

If you answered yes to the question above, please continue with the following:
How many days per week do you exercise? ________
How many minutes each day? ________
Approximately how long have you been exercising regularly?________________

Assign a number 1 through 5 to rate the following statements according to
your perception of the following:
(1 represents the lowest level, 5 represents the highest level)

How fit do you currently feel
___ 1 ___ 2 ___ 3 ___ 4 ___ 5
The discipline you have to maintain a consistent workout routine on your own
___ 1 ___ 2 ___ 3 ___ 4 ___ 5
Your capacity for aerobic activity
___ 1 ___ 2 ___ 3 ___ 4 ___ 5
Your muscular strength
___ 1 ___ 2 ___ 3 ___ 4 ___ 5
Your body’s flexibility
___ 1 ___ 2 ___ 3 ___ 4 ___ 5
Your current level of energy
___1 ___2 ___3 ___4 ___5
How much time will you devote to an exercise program?
_______ days per week _______ minutes per day
List any injuries that would hinder some of your exercise abilities. List date/year
of injury.

_____________________________               _____________
_____________________________               _____________

What are your current fitness goals?
________________________________________________________________
________________________________________________________________
(ex. toning, weight loss, build muscle, etc)

Diet and Nutrition History:
How would you describe your daily nutritional habits?
unhealthy irregular healthy

List any vitamins and supplements that you take on a regular basis.
________________________________________________________________
________________________________________________________________
________________________________________________________________

Medical History:
Are you currently under a doctor’s care? yes no
If yes, explain:
________________________________________________________________
________________________________________________________________

When was the last time you had a physical examination (mm/dd/yy)?
________________
Have you recently been hospitalized? yes no
If yes, explain:
________________________________________________________________
________________________________________________________________

Do you smoke? yes  no
Are you pregnant? yes no
Do you consider your stress level to be high? yes no

Do you have any of the following?
high blood pressure yes no
high cholesterol yes no
diabetes yes no
known heart disease yes no
a heart murmur yes no
chest pain during physical activity yes no
irregular heart beat or palpitations yes no
lightheadedness or fainting spells yes no
unusual shortness of breath yes no
cramping pains in legs or feet yes no
emphysema yes no
thyroid or kidney disorders yes no
epilepsy yes no
asthma yes no
back pain yes no

Do you any other pain or limitation not yet mentioned? yes no
If yes, describe:
________________________________________________________________
________________________________________________________________


I acknowledge that all said information above is accurate and without misrepresentation.
If at any time, it is found that I have provided false information, my contract with Body
by Raheem and all of its associates will become null and void.


                                             ___________________________________
                                                        client’s signature


                                             ___________________________________
                                                            date




Body by Raheem 7/11/2010

				
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Description: Personal Fitness Questionnaire