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Online Training Form 2

This new online program allows you to have the guidance of a personal trainer at an affordable price. This program is perfect for someone who is currently working out and just needs a little boost to their program and just some extra motivation to break through a plateau. With this service you will receive:

• A strength training program with pictures and descriptions that will be updated every month.

• A weekly cardio routine suited to your preferences.

• Nutritional guidance.

• Monthly fitness tips.

• Additional phone/email support to answer any questions that you may have.

Please fill out the following form.

Your Name:
   
Email Address:
   
Phone Number:
   
Address:
   
Sex:  Age: 

Health Screening Questionnaire

History: Have you had -  
A heart attack
   
Heart surgery
   
Cardiac catheterization
   
Coronary angioplasty (PTCA)
   
Pacemaker/implantable cardiac defibrillator
   
Heart valve disease
   
Heart failure
   
Heart transplant
   
Congenital heart disease
   
Symptoms: Do you
Experience chest discomfort with exertion
   
Experience unreasonable breathlessness
   
Experience dizziness, fainting, blackouts
   
Take heart medications
Other health issues: Do you have  
   
Diabetes
   
Asthma or other lung disease
   
Burning or cramping in your lower legs when walking short distances
   
Musculoskeletal problems that limit your physical activity
   
Concerns about the safety of exercise
   
Take prescription medication(s)
   
Are you pregnant
   
Cardiovascular Risk Factors*  
   
Are you a man older than 45 years
   
Are you a woman older than 55 years, or you have had a hysterectomy, or you are postmenopausal
   
Do you smoke or have quit in the previous six months
   
Do you know your blood pressure
   
Is your blood pressure greater than 140/90
   
Do you take blood pressure medication
   
Do you know your cholesterol level
   
Is you cholesterol level >200 mg/dL
   
Do you have a close blood relative who had a heart attack before age 55 (male) or age 65 (female)
   
Are you physically inactive (i.e., you get less than 30 min. of physical activity on at least 3 days per week)
   
Are you more than 20 pounds overweight
   
Do you know of any other physical condition or aliment that you have that would prevent you or hinder you from performing  workouts or participating in cardio exercises.  Please list any information that you think your trainer should know.
   
By initialing this box you indicate that you have answered the about questions truthfully and to the best of your ability. 
   

 

 

*If you marked yes to two or more of the statements in this section, you should consult your physician or other appropriate healthcare provider before engaging in exercise.