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Fitness By Day Health History Questionnaire
Please answer each question accurately and carefully. All
information submitted on this form will be kept confidential. As
always, you should consult your physician before beginning any
exercise program.
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Yes |
No |
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Has anyone in your immediate family had a heart attack, stroke, or
cardiovascular disease before age 55? |
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Has your doctor told you that your cholesterol level is too high? |
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Do you currently smoke? |
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Are you a male over 39 years of age? |
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Are you a female over 49 years of age? |
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Are you currently engaging in physical activity less than 1 hour per
week? |
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Do you have any cardiovascular or respiratory problems? |
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Do you have epilepsy? |
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Are you pregnant? |
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Do you have diabetes? |
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Do you have an eating disorder? |
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Do you feel pain in your chest when you engage in physical activity? |
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Do you ever lose consciousness or do you ever lose control of your
balance due to chronic dizziness? |
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Do you have a bone or joint problem that could be made worse by a
change in your physical activity? |
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Has your doctor told you that your blood pressure is too high, or
are you currently taking drugs for your blood pressure? |
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Do you know of any other reason why you should not exercise?
Please Explain:
Please list any medications you are taking.
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I have read, understood, and completed this questionnaire. Any
questions I had were answered to my full satisfaction. |
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Name |
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Date |
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E-Mail Address
Phone Number
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Date of Birth
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Did anyone refer you to FitnessByDay.com? Who?
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Goals and Current Health and Exercise Status
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Do
you have any health problems that may impact your ability to
exercise? If so, please describe.
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Are
there any areas of your body you are particularly stiff or sore?
If so, where and to what degree?
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What are your top three fitness goals?
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What days and times would you prefer to workout?
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Yes |
No |
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Have you exercised in the past? |
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Are you exercising currently? |
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What does your current program consist of?
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How effective has this program been for you?
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What are the top 3 lifestyle, motivational, time constraints, and
other challenges do you expect to encounter?
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Yes |
No |
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Have you had a personal trainer in the past? |
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If so, what was the experience like for you?
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What expectations do you have as a member of Fitness By Day?
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Your New Program
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Where do you plan to exercise? (at home, gym, etc.)
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What types of exercise equipment do you have access to? (free
weights, weight machines, stairmaster, treadmill, etc.)
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Yes |
No |
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Do you have a workout partner? |
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What time of day do you plan to exercise?
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How many days per week do you expect to exercise?
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How many minutes do you have to exercise on the days you do?
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Diet
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Have you ever been on a diet in the past? If "yes" please explain.
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Are
you currently on any specific diet? If yes, please explain.
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Do you usually eat breakfast?
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How many times per week do you eat or drink the following? |
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Beef |
Fried Foods |
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Pork |
Fast Food |
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Fowl |
Butter |
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Fish |
Sugar |
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Desserts |
Milk |
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Yes
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No
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Are you a vegetarian? |
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What types of foods do you enjoy most?
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How
many meals do you eat per day?
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How many times per day do you eat snacks and what snacks do you
normally eat?
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What do you perceive as your top 3 dietary challenges?
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