Isu Wellness Center Fitness Assessment Client Information Form (Page 2 of 2) in pdf

Fitness A ssessment C lient I nformation F orm

Last n ame:

First n ame:

MI:

Address:

City/State:

Zip C ode:

Telephone:

E-‐ m ail a ddress:

Bengal c ard n umber:

ISU A ffiliation:

Emergency c ontact p erson:

Relationship:

Home t elephone:

Cell p hone:

Work t elephone:

Personal H ealth I nformation

Date o f b irth:

Age:

Height:

inches o r c m Current w eight:

lbs. o r k g

Resting h eart r ate ( RHR):

Resting b lood p ressure ( if k nown):

Health R isk A ssessment

To p rovide y ou w ith t he b est s ervice p ossible, i t i s i mportant f or u s t o r eview i ssues t hat m ight i mpact y our

health. T his f orm i s c onfidential a nd w ill b e k ept i n y our f ile i n t he I SU W ellness C enter. T he I SU W ellness

Center s taff w ill n ot r elease t his i nformation w ithout y our w ritten c onsent, u nless r equired b y l aw.

Please l ist m edications ( prescription, o ver-‐ t he-‐ c ounter, d ietary s upplements) t aken r egularly a nd t he

reason f or t aking:

2. Please l ist a ny f ood o r d rug a llergies:

3. Do y ou u se t obacco p roducts?

If y es, h ow o ften a nd h ow m uch?

4. Have y ou ( or a f amily m ember) e ver b een t old t hat y ou h ave d iabetes?

5. Do y ou h ave a ny k nown c ardiovascular p roblems ( abnormal E CG, a therosclerosis, h eart a ttack, h igh

blood p ressure)? £ Y es £ N o I f y es, p lease e xplain:

6. Has y our d octor e ver t old y ou y our c holesterol l evel i s h igh?

7. Women o nly: A re y ou p regnant o r d id y ou h ave a b aby l ess t han s ix w eeks a go? £ Y es £ N o

8. Please w rite w hat y ou c onsider a h ealthy w eight f or y ourself:

pounds o r

k g

9. Are y ou a t o r w ithin t en p ounds o f y our d esired w eight? £ Y es £ N o

10. Are y ou t rying t o l ose w eight? £ Y es £ N o

If y es, p lease d escribe t he m ethod o f w eight l oss y ou a re u sing:

Physical A ctivity R eadiness Q uestionnaire ( Par-‐ Q )

This q uestionnaire w ill t ell y ou w hether i t i s n ecessary f or y ou t o s eek f urther a dvice f rom y our d octor O R a

qualified e xercise p rofessional b efore b ecoming m ore p hysically a ctive.

YES NO

£ Has y our d octor e ver s aid t hat y ou h ave a h eart c ondition a nd t hat y ou s hould o nly d o p hysical

£

activity r ecommended b y a d octor?

£ Do y ou f eel p ain i n y our c hest w hen y ou d o p hysical a ctivity?

£

£ In t he p ast m onth, h ave y ou h ad c hest p ain w hen y ou w ere n ot d oing p hysical a ctivity?

£

£ Has y our d octor e ver s aid t hat y ou h ave h igh b lood p ressure?

£

£ Is y our d octor c urrently p rescribing d rugs ( for e xample, w ater p ills) f or y our b lood p ressure o r

£

heart c ondition?

£ Do y ou l ose b alance b ecause o f d izziness o r d o y ou e ver l ose c onsciousness?

£

£ Do y ou h ave a b one o r j oint p roblem s uch a s a rthritis t hat c ould b e m ade w orse b y a c hange i n

£

your p hysical a ctivity?

£ Have y ou e ver b een d iagnosed w ith a nother c hronic m edical c ondition ( other t han h eart d isease o r

£

high b lood p ressure)?

£ Has y our d octor e ver s aid t hat y ou s hould o nly d o m edically s upervised p hysical a ctivity?

£

£ Do y ou k now o f a ny o ther r eason w hy y ou s hould n ot d o p hysical a ctivity?

£

Isu Wellness Center Fitness Assessment Client Information Form Page 2

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