My FAC 101

Member's Name
Date
Age
Email
Phone
Best way to reach me	Email     Phone
INTEREST:
Tennis	Aquatics
Group Fitness Classes	Pilates
Yoga	Machines/Free Weights
Cardio/Running	Cycling
GOALS:
1.
2.
3.
HEALTH HISTORY:
1. Are you currently being treated for high blood pressure? Yes    No
2. Have you been told that your cholesterol levels are high? Yes    No
3. Have you smoked cigarettes in the past 12 months? Yes    No
4. Has any member of your immediate family developed heart disease or had a stroke before age 55? Yes    No
5. Has a doctor said you have a heart condition? Yes    No
6. Do you experience chest pain/discomfort brought on by exercise or during participation in physical activity? Yes    No
7. Have you recently developed chest pain/discomfort that has been evaluated by your doctor and found to be unrelated to a heart problem? Yes    No
8. Do you have diabetes? Yes    No
9. Do you often feel faint or have spells of severe dizziness? Yes    No
10. Do you have a bone or joint problem (such as arthritis) or an old injury that could be exacerbated with exercise? Yes    No
11. Are you presently under a doctor's care for any disease or condition? Yes    No
12. Are you currently taking any medication for any disease or condition? Yes    No
13. Are you aware, through your own experience or doctor's advice, of any physical reason (including pregnancy) which would prevent you from exercising without medical supervision? Yes    No
COMMENTS OR CONCERNS: