Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
DOB
MM
DD
YYYY
Height and weight
Gender
Phone
(###)
###
####
Email
*
Are you a male older than 45 years?
*
Female older than 55 years?
*
Female who has experienced premature menopause without estrogen replacement therapy?
*
Do you have a father or brother who has had a heart attack or sudden death before the age of 55?
*
A mother or sister who has had a heart attack or sudden death before 65?
*
Do you smoke?
*
Do you have diabetes?
*
Do you have high blood pressure?
Do you have high Cholesterol?
*
Do you lead a sedentary lifestyle (inactive job and no active lifestyle or recreational pursuits)?
Do you have any personal history of coronary or atherosclerotic disease?
*
Do you have any personal history of metabolic disease (thyroid, renal (kidney), liver)?
*
Are you diabetic?
*
High blood pressure?
Do you have high cholesterol? If yes, are you on a physician approved diet?
*
Do you have any personal history of coronary or atherosclerotic disease?
*
Do you have any personal history of metabolic disease (thyroid, renal/kidney, liver)?
*
Do you have any personal history of metabolic disease (thyroid, renal/kidney, liver)?
*
Have you been diagnosed with or exhibited symptoms of any of the following conditions: (please check all that apply)
*
If yes, please explain:
All information is treated confidentially.
Has your doctor ever recommended/prescribed any medication for blood pressure or a heart condition?
Are you taking any other prescription or non-prescription medications?
*
If yes please list all medication.
Injuries or Other Orthopedic Limitations: Check the areas that have been injured both recently and in the past.
If you checked off any of the above injuries/limitations, please explain with as much information as possible:
Are you presently receiving physical therapy?
Are you aware of any medical or other personal limitations not covered by this questionnaire which would restrict your participation in a program of physical activity?
*
What are your main exercise interests? (check all that apply)
Please describe your MEASURABLE exercise objectives in detail: Short-Term Goals (2 to 4 months) and long-term goals (8 to 12 months)
*
What is your why?
*
Why are you here right now? What made you decide to TODAY to make contact with MFSC and take the very first step to your goal?
Where do you prefer to vacation?
City
Beach
Mountains
