Personal info
Check any symptoms of possible coronary or metabolic disease you have recently experienced: Chest painshortness of breathdizzy/faintingankle swellingheart palpitationsleg/feet crampingheart murmur
Risk factors for CHD (Coronary Heart Disease), MI (heart attack), Stroke or hypertension (usually caused by atherosclerosis):
Do you smoke? NoYes How much? perDayWeekMonth Did you quit smoking less than 6 months ago? NoYes Do you take antihypertensive medications? NoYes Are you currently taking Beta-blockers? NoYes Do you get at least 30 minutes of moderate physical activity everyday? NoYes Do you have osteoporosis? NoYes Do you have osteoarthritis? NoYes Do you suffer from back pain? Yes(upper)Yes(mid)Yes(low)No If yes, how often? RarelyDailyWeeklyMonthly Are you often stressed? NoYes If yes, how does it physically manifest? HeadacheStomachSleeplessIrritableOther How many times do you get sick (common cold) per year? 1234More Do you have diabetes? NoYes(type I)Yes(type II) Do you eat low, moderate or high carbs? LowMidHigh Do you eat low, moderate or high protein? LowMidHigh Do you eat low, moderate or high fat? LowMidHigh Do you eat a variety of foods (whole grains, dairy, lean meats, fruit & vegetables with limited fat/oils)? YesNo
What level of importance do you place on exercise? NoneLowAverageModerateEssential How many days per week do you want to commit to exercise? 1234567 How many minutes per day? 20 or lessabout 304560an hour (+)
Rate your fitness (1-Poor, 5-Average, 10-Excellent): Cardio-Respiratory 12345678910 Strength 12345678910 Endurance 12345678910 Flexibility 12345678910 Power 12345678910 Body Composition 12345678910 Self-Image 12345678910
