Subscriber Signup / Exercise Intake Form

Your First Name (required)

Your Last Name (required)

Location (City and State)

Phone Number-Include Area Code

Your Email (required)

Gender
Male
Female

Date of Birth

What is your current bodyweight (pounds)?

What is your height (inches)?

Current Exercise Status:

Health and Exercise Related Questions:

1. Has anyone in your immediate family had a heart attack or died suddenly of a heart-related disorder before age 55 (men) or 65 (women)?

2. Are you on medication for high blood pressure or is your blood pressure higher than 140/90?

3. Is your total cholesterol greater than 200 mg/dl or is your HDL cholesterol less than 35 mg/dl?

4. a. Do you have diabetes?

4. b. If you answered yes, what type of diabetes do you have?

5. Please indicate the duration and frequency of time spent in each of the following physical activities:

Aerobic Exercise (Duration):

Strength Training - Weights, machines, etc. (Dur.):

Stretching and/or Yoga (Duration):

Active Sports - Tennis, soccer, lacrosse, etc. (Dur.):

Occupational Activity - Walking, lifting, etc. (Dur.):

Household Activity - Housework, gardening (Dur.):

Aerobic Exercise (Frequency):

Strength Training (Frequency):

Stretching and/or Yoga (Frequency):

Active Sports (Frequency):

Occupational Activity (Frequency):

Household Activity (Frequency):

6. Do you smoke cigarettes?

7. Has your doctor or other health professional ever told you that you have a heart condition?

8. Do you ever feel pain or discomfort in your chest when you engage in physical activity?

9. Do you ever experience dizziness or even lose consciousness?

10. Do you have a bone, joint or muscle problem that could be made worse by participating in a physical activities?

11. If you answered "Yes" to the previous question, which areas may become aggravated with physical activity? (Check all that apply):
FootAnkleLower LegKneeUpper LegHipGroinLower BackUpper BackChestNeckShoulderUpper ArmElbowForearmHandNot Applicable

12. Are you pregnant?

Any reason why participating in an exercise program/physical activity could be harmful to your health? Please explain:

Any other physical limitations that could impact your ability to engage in certain physical activities? Please describe:

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