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
Male
Female
Phone
(###)
###
####
Email
*
Are you a male older than 45 years?
*
Yes
No
Female older than 55 years?
*
Yes
No
Female who has experienced premature menopause without estrogen replacement therapy?
*
Yes
No
Do you have a father or brother who has had a heart attack or sudden death before the age of 55?
*
Yes
No
A mother or sister who has had a heart attack or sudden death before 65?
*
Yes
No
Do you smoke?
*
Yes
No
Occassionally
Do you have diabetes?
*
Yes
No
Do you have high blood pressure?
Yes
No
Do you have high Cholesterol?
*
Yes
No
Do you lead a sedentary lifestyle (inactive job and no active lifestyle or recreational pursuits)?
Yes
No
Occassionally
Do you have any personal history of coronary or atherosclerotic disease?
*
Yes
No
Do you have any personal history of metabolic disease (thyroid, renal (kidney), liver)?
*
Yes
No
Are you diabetic?
*
Yes
No
High blood pressure?
Yes
No
Do you have high cholesterol? If yes, are you on a physician approved diet?
*
Yes
No
Do you have any personal history of coronary or atherosclerotic disease?
*
Yes
No
Do you have any personal history of metabolic disease (thyroid, renal/kidney, liver)?
*
Yes
No
Do you have any personal history of metabolic disease (thyroid, renal/kidney, liver)?
*
Yes
No
Have you been diagnosed with or exhibited symptoms of any of the following conditions: (please check all that apply)
*
Abnormal EKG
Anemia
Aneurysm
Angina
Ankle edema
Anxiety attacks
Asthma
Breathing problems at night
Claudication Cardiac Surgery
After-effects of COVID-19
Dizziness or fainting
Embolism
Emphysema
Epilepsy
Fixed Rate Pacemaker
Heart murmur
Motion sickness
Rapid Heart Rate
Chronic respiratory Infections
Shortness of breath
Stroke
Thrombophlebitis
Valve Disease
Vascular Disease
None of the above
If yes, please explain:
All information is treated confidentially.
Has your doctor ever recommended/prescribed any medication for blood pressure or a heart condition?
Yes
No
Are you taking any other prescription or non-prescription medications?
*
Yes
No
If yes please list all medication.
Injuries or Other Orthopedic Limitations: Check the areas that have been injured both recently and in the past.
ACL
Ankle
Bursitis
Elbow
Fractures, dislocations, or breaks
Hip
Knee(s)
Lower back
Neck or shoulder
Nerve damage
Osteoarthritis
Osteoporosis
Spinal
Wrist
Osteopenia of hip, osteoporosis of lower spine
If you checked off any of the above injuries/limitations, please explain with as much information as possible:
Are you presently receiving physical therapy?
Yes
No
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?
*
Yes
No
What are your main exercise interests? (check all that apply)
Personal fitness training
Strength and conditioning
Improved cardiovascular health
Competitive physique/bodybuilding/figure/bikini contest prep
Competitive powerlifting
League sports training
Online training
Virtual face-to-face training
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