Fitness Pro Health Questionnaire Form - Certified Fitness Trainer Oscar Gonzalez

Oscar Gonzalez, internationally-acclaimed certified fitness trainer

Fitness Pro - Certified Fitness Trainer Oscar Gonzalez - Hamptons Long Island New York

Health Questionnaire Form of Fitness Pro Oscar Gonzalez, internationally-acclaimed certified personal fitness trainer and group fitness instructor

Fitness Pro - Health Questionnaire

PERSONAL INFORMATION

First name:

Last name:

Today's date:

Date of birth (mm/dd/yyyy):

Sex:

Male

Female

Height:

Weight:

Address:

City:

State:

Zip:

Home phone:

Work phone:

Cell phone:

Email:

Please confirm email:

Email:

Employer:

Occupation:

In case of emergency, please notify:

Name:

Relationship:

Address:

City:

State:

Zip:

Phone:

Cell phone:

Email:

MEDICAL INFORMATION

Physician:

Physician's phone:

Are you under the care of a physician, chiropractor, or other health care professional for any reason?

Yes

If yes, list reason:

Are you taking any medications?

Yes

If yes, complete the following:

Type:

Dosage/frequency:

Reason for taking:

Please list any allergies:

Has your doctor ever said your blood pressure was too high?:

Yes

Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?:

Yes

Are you over age 65?:

Yes

Are you unaccustomed to vigorous exercise?:

Yes

Is there any reason not mentioned here why you should not follow a regular exercise program?:

Yes

If so, please explain:

Have you recently experienced any chest pain associated with either exercise or stress?:

Yes

If so, please explain:

Smoking

Please check the box that best describes your current habits:

	Non-user
	Former user Date quit:
	Cigar and/or pipe
	15 or less cigarettes per day
	16 to 25 cigarettes per day
	26 to 35 cigarettes per day
	More than 35 cigarettes per day

FAMILY AND PERSONAL MEDICAL HISTORY

Do you now, or have you had in the past:

Lifestyle and Dietary Factors

Occupation stress level:

Low

Medium

High

Energy level:

Low

Medium

High

Caffeine intake per day:

Alcohol intake per week:

Colds per year:

Anemia:

Gastrointestinal disorder:

Hypoglycemia:

Thyroid disorder:

Pre/postnatal:

Cardiovascular

High blood pressure:

Hypertension:

High cholesterol:

Hyperlipidemia:

Heart disease:

Heart attack:

Stroke:

Angina:

Gout:

Musculoskeletal Information
Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain or general discomfort:

Head/neck:

Upper back:

Shoulder/clavicle:

Arm/elbow:

Wrist/hand:

Lower back:

Hip/pelvis:

Thigh/knee:

Arthritis:

Hernia:

Surgeries:

Other:

Nutritional Information

Are you on any specific food/nutritional plan at this time?:

Yes

If yes, please list:

Do you take dietary supplements?:

Yes

If yes, please list:

Do you experience any frequent weight fluctuations?:

Yes

Have you experienced a recent weight gain or loss?:

Yes

If yes, please list:

Over what period of time:

How many beverages do you consume per day that contain caffeine?:

How would you describe your current nutritional habits?:

How many meals and/or snacks do you have per day?:

Other food/nutrition issues you want to include (food allergies, mealtimes, etc.):

Exercise Habits

Please check off 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

To what degree do you perceive your environment as stressful?:

	Minimal
	Moderate
	Average
	Extremely

Do you work more than 40 hours a week?:

Please make any other comments you feel are pertinent to your exercise program:

SCREENING

Has a doctor ever said you have heart trouble?:

Yes

Have you ever had angina pectoris, sharp pain, or heavy pressure in your chest as a result of exercise, walking, or other physical activity such as climbing stairs (Note: this does not include the normal out of breath feeling that results from normal activity.)?:

Yes

Do you experience any sharp pain or extreme tightness in your chest when you are hit with a cold blast of air?:

Yes

Have you ever experienced rapid heart action or palpitations?:

Yes

Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, coronary insufficiency, or thrombosis?:

Yes

Have you ever had rheumatic fever?:

Yes

Do you have diabetes, hypertension or high blood pressure?:

Yes

Does anyone in your family have diabetes, hypertension or high blood pressure?:

Yes

Has more than one blood relative (parent, sibling, first cousin) had a heart attack or coronary artery disease before the age of 60?:

Yes

Have you ever taken any medication to lower your blood pressure?:

Yes

Have you ever taken medications or been on a special diet to lower your cholesterol?:

Yes

Have you ever taken digitalis, quinine, or any other drug for your heart?:

Yes

Have you ever taken nitroglycerine or any other tablets for chest pain - tablets you take by placing under the tongue?:

Yes

Are you overweight?:

Yes

Are you under a lot of stress?:

Yes

Do you drink excessively?:

Yes

Do you smoke cigarettes?:

Yes

Do you have a physical condition, impairment or disability, including a joint or muscle problem, that should be considered before you undertake an exercise program?:

Yes

Are you more than 65 years old?:

Yes

Are you more that 35 years old?:

Yes

Do you exercise fewer than three times per week?:

Yes

Are you pregnant now or in the past three months?:

Yes

EXERCISE HISTORY

Are you currently involved in a regular exercise program?:

Yes

Do you practice weightlifting or calisthenics?:

Yes

If yes, how many times per week?

Are you currently involved in an aerobic program?:

Yes

If yes, what type?:

How many times per week?:

Do you frequently compete in competitive sports?:

Yes

If yes, which one(s)?

If other, please specify:

Average number of times per week:

In which of the following high school or college athletics did you participate?:

If other, please specify:

What is your primary fitness goal?:

How many days each week are you available to workout?:

What equipment is available to you?:

Additional comments:

I hereby certify that the above information is accurate and I authorize Fitness Pro to contact me about a specific exercise plan

Oscar Gonzalez, internationally-acclaimed certified fitness trainer