Pg Fit Fitness Assessment Form
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1
2FITNESS ASSESSMENT FORM
PERSONAL INFORMATION
Today’s Date: _______________
Date of Birth: _____________________ Male Female
Name:_________________________________
Occupation: _____________________________ Email: ___________________________________________
Address:__________________________________________________________________________________
City: _____________________________ State: _______ Zip Code: ________
Day Phone: _________________Evening Phone: __________________Cell Phone______________________
Emergency Contact_______________________ Phone: ________________ Relation:__________________
Dr. Name:_______________________________ Phone: ________________
PHYSICAL ACTIVITY & MEDICAL HISTORY
YES NO YES NO
Has a doctor ever said you have a heart condition and recommended
___ ___
1.
Heart Condition
only medically supervised activity?
___ ___
___ ___
Diabetes
2. Do you have chest pain brought on by physical activity? ___ ___
___ ___
Asthma
3. Do you tend to lose consciousness or fall over a result of dizziness?
___ ___
___ ___
Short of Breath
4. Has a doctor ever recommended medication for your blood pressure
___ ___
Arthritis Bursitis
or a heart condition?
___ ___
___ ___
Rheumatism
5. Do you have a bone or joint problem that could be aggravated by the
___ ___
Hernia
proposed physical activity?
___ ___
___ ___
Recent Surgery
6. Are you aware, through your own experiences or a doctor’s advice,
__ ____
Sacroiliac Problem __
of any other physical reason against your exercising without medical
___ ___
Angina
service?
___ ___
High Blood Pressure____ _____
7. Are you over the age of 65 and not accustom to vigorous exercise?
___ ___
___ ___
Knee Problems
___ ___
Back Problems
If you answered YES to any of the above, please answer the following:
Cervical Thoracic Lumbar
8. Have you
consulted your physician regarding increasing your physical
activity and/or performing a
If “YES” to any of the above
fitness assessment?
___ ___
please see Fitness Manager
9. If you answered NO to question 8, will you consult your physician prior
scheduled.
before exercise is
to increasing your physical activity and performing a fitness assessment?___ ___
I certify that the above statements are true and correct. I understand that a Doctor’s note may be
requested. If a note is requested, I should not proceed with this workout until the note is received.
Member Signature: ____________________________________
Date: _____________________
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