Member Assessment Form Personal Information First Name Last Name Email Phone Number Address City State Zip Code Birthday Occupation Marital StatusMarriedSingle GenderMaleFemalePrefer not to share Height Physical Activity Readiness Has a doctor ever said you have a heart condition and recommended only medically supervised physical activity?YesNo Do you have chest pain brought on by physical activity?YesNo Do you tend to lose consciousness or fall over as a result of dizziness?YesNo Has a doctor ever recommended medication for your blood pressure or a heart condition?YesNo Are you aware through you own experiences or a doctor’s advice of any other physical reason against your exercising without medical supervision?YesNo Do you have a bone or join problem that could be aggravated by the proposed physical activity?YesNo Are you over the age of 65 and not accustomed to vigorous exercise?YesNo Have you consulted your physician regarding increasing your physical activity and/or performing a fitness assessment?YesNo If you answered NO to question 8, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?YesNo Do you take any medications, either prescription or non-prescription, on a regular basis?YesNo What is the medication for? How does this medication affect your ability to exercise or achieve your fitness goals? Have you ever had any major surgery?YesNo If so, what and when? Have you ever had any injury in the past?YesNo If so, what kind of injury and when? Are you currently injured?YesNo If so, what kind of injury and when? Medical History Please mark all that apply Heart Disease or StrokeAlways/Very OftenSometimesRarely/Never High Blood PressureAlways/Very OftenSometimesRarely/Never Food Allergies (Confirmed)Always/Very OftenSometimesRarely/Never Lung / Pulmonary Disease (Difficult Breathing)Always/Very OftenSometimesRarely/Never Kidney / Liver DiseaseAlways/Very OftenSometimesRarely/Never Neuromuscular DiseaseAlways/Very OftenSometimesRarely/Never Gastrointestinal DiseaseAlways/Very OftenSometimesRarely/Never DepressionAlways/Very OftenSometimesRarely/Never DiabetesAlways/Very OftenSometimesRarely/Never ArthritisAlways/Very OftenSometimesRarely/Never AnorexiaAlways/Very OftenSometimesRarely/Never BulimiaAlways/Very OftenSometimesRarely/Never Chronic PainAlways/Very OftenSometimesRarely/Never CancerAlways/Very OftenSometimesRarely/Never UlcerAlways/Very OftenSometimesRarely/Never ArteriosclerosisAlways/Very OftenSometimesRarely/Never Gallbladder DiseaseAlways/Very OftenSometimesRarely/Never Low Back Pain (Within last 6 months)Always/Very OftenSometimesRarely/Never Psychological ProblemsAlways/Very OftenSometimesRarely/Never Compulsive Overeating DisorderAlways/Very OftenSometimesRarely/Never Pregnant / Lactating or Trying to ConceiveAlways/Very OftenSometimesRarely/Never Lifestyle Related Questions Do you smoke?YesNo If yes, how many? Do you drink alcohol?YesNo If yes, how many glasses per week? How many hours do you regularly sleep at night? Describe your job:SedentaryActivePhysically Demanding Does your job require travel?YesNo On a scale of 1-10, how would you rate your stress level List your 3 biggest sources of stress: Is anyone in your family overweight?MotherFatherSiblingGrandparent Were you overweight as a child?YesNo If yes, at what age(s)? Fitness History When were you in the best shape of your life? Have you been exercising consistently for the past 3 months?YesNo When did you first start thinking about getting in shape? What, if anything, stopped you in the past? On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)? How often do you take part in physical activity?5-7x/ week3-4x/week1-2x/week Nutrition Related Questions On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)? How many times a day do you usually eat (including snacks)? Do you skip meals?YesNo Do you eat breakfast?YesNo Do you eat late at night?Always/Very OftenSometimesRarely/Never What activities do you engage in while eating? (TV, reading etc) How many glasses of water do you consume daily? Do you feel drops in your energy levels throughout the day?YesNo If yes, when? Do you know how many calories you eat per day?YesNo If yes, how many? Are you currently or have you ever taken a multivitamin or any other food supplements?YesNo If yes, please list the supplements: At work or school, do you usually:Eat OutBring Food How many times per week do you eat out? Do you do your own grocery shopping?YesNo Do you do your own cooking?YesNo Besides hunger, what other reason(s) do you eat?—Please choose an option—BoredomSocialStressedTiredDepressedHappyNervousOther Do you eat past the point of fullness?Always/Very OftenSometimesRarely/Never Do you eat foods high in fat and sugar?Always/Very OftenSometimesRarely/Never List 3 areas of your Nutrition you would like to improve: Any additional comments or concerns? Check here if you accept our terms (Privacy Policy) By checking this box you agree that the above information is correct to the best of your knowledge.
