PERSONAL INFORMATIONName: Date of Birth: DD slash MM slash YYYY Age:PLEASE CHECK ANY OF THE FOLLWING PRE - EXISTING OR EXISTING MEDICAL CONDITIONS YOU MAY HAVE Anxiety Disorder Chronic Fatigue Syndrome Diabetes Heart Disease Kidney Disease Osteoporosis Sleep Apnea Syndrome Aortic Valve Disease Colon Cancer Eating Disorder Hernia Lung Disease Pain: Neck | Back | Shoulder | Hip | Leg Stroke Asthma Coronary Artery Disease Emphysema High Blood Pressure Mental Illness Prostate Cancer Thyroid Disorder Breast Cancer Depression Fibromyalgia High Cholesterol Obesity Seizures Other – Please List Below OTHER:Please list any medications & supplements including over the counter drugs with dosage & frequency : Stress Level Rate (1 – 10, 10 Being The Max) : Fitness Level Rate ( 1 – 10, 10 Being The Max ) : What physical activity, if any, have you performed in the past 30, 60, 90 Days: Recreational Activities (Golfing, Hiking, Swimming, Tennis, Etc.?): What are your fitness goals : Have you ever worked with a Personal Trainer? If so, what did you like or dislike about the experience? Is there any medical or physical condition that you currently have or have ex perienced in the past which would affect your ability to participate in personal training which can contain strenuous activities? Δ
