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Does your profession involve sitting for a large part of the day?
No Yes
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What are your specific goals? (i.e. weight loss, gain muscle, toning lower body, etc.)
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For general scheduling purposes only (no commitment), what days and times are best for you to visit us? The more specific you can be the easier to match you with a trainer. (i.e. Monday's at 6 p.m. or after, Wednesday mornings before 10 a.m., Saturday's anytime, etc.)
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For general scheduling purposes only (no commitment), how often do you wish to visit us? (i.e. 3 times per week for several months, only a few visits, once every two weeks for 4 months, etc.)
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How many times per week do you currently exercise? Days
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How would you describe the intensity of this exercise?
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How long have you been exercising?
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What is the duration of a typical session? Minutes
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What types of exercise do you perform?
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What level of exercise do you wish to perform with us?
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Do you currently smoke?
No Yes
... If yes how many per day? per Day
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Have you quit smoking in the last 2 years?
No Yes
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Do you often have pains in your heart, chest, or surrounding areas, especially during exercise?
No Yes
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Do you often feel faint or have spells of severe dizziness during exercise?
No Yes
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Do you experience unusual fatigue or shortness of breath at rest of with mild exhertion?
No Yes
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Have you had an attack of shortness of breath that came on after you had stopped exercising?
No Yes
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Do you experience swelling or accumulation of fluid in and around the ankles?
No Yes
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Do you often get the feeling that your heart is racing or skipping beats, either at rest or during exercise?
No Yes
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Do you regularly get pains in your calves or lower legs that are not due to soreness or stiffness?
No Yes
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List any diseases (including high blood pressure) that a doctor has told you that you have (Enter NONE if you have no known diseases):
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Have you ever been told that you have diabetes?
No Yes
If Yes, what type:
How long have you had it: per Day
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List any medications that you take on a regular basis (Enter NONE if you take no medications):
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Only if known, enter the following:
Total Cholesterol:
Blood Pressure:
HDL Cholesterol:
Triglycerides:
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Has your father, mother, brother, or sister had a heart attack, or suffered, or died from cardiovascular disease before the age of 65?
No Yes
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If yes, was it a male or female relative?
Male Female
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How old were they when they were diagnosed?
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Is it possible that you are pregnant?
No Yes
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Have you experienced menopause before the age of 45?
No Yes
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If yes, are you currently taking hormone replacement therapy?
No Yes
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Email Address
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