Members Only | Pure Conditioning

Name*

Address: (home)

City: (home)

State: (home)

Zip-Code: (home)

Phone: (home)

Phone: (mobile)

Email:

Occupation:

Address: (work)

Phone: (work)

Phone II: (work)

DOB:

Age:

Sex:

Height:

Weight:

Desired Weight:

Does your occupation require you to perform any physically demanding activity?

Exercise

Which exercise goals and/or results are most important to you? Check all that apply:

Rate your commitment level to achieving these goals.

Number of months expected to attain goal:

What would you like to see change on your body in one month?

What would you like to look like 1 year from now?

What exercise and/or recreational activities have you participated in during the past, are currently engaged in, or plan to engage in the future?

How many days are you committed to workout each week?

How would you rate your exercise level:

Sedentary => Little or no recent history

Beginner => New exercise within past 6 months

Intermediate => Exercising regularly for the past year

Advanced => Well conditioned individuals

Professional => Amateur or professional athletes

How would you classify your current activity level?

Inactive

Light activity (i.e. a little walking)

Moderate activity (i.e. walking, light jogging, “taking the stairs”)

Demanding activity (i.e. running, aerobics)

Very demanding activity (i.e. strength training, mountain climbing)

Extended activity (i.e. triathlon or marathon running)

How much time per week do you exercise currently?

Have you ever worked out with a personal trainer?

If yes, were you pleased with the results and level of service? Please explain.

Rate your level of Daily Stress:

Diet

How much water do you think you should drink per day?

How much water do you drink per day?

Do you use a water filter at home and work? If so what type/brand?

Do you drink alcohol?

If so, how much?

What other beverages do you drink?

List any food allergies:

List any foods that you refuse to eat:

Are you taking any supplements?

If so, which ones?

How often do you eat home cooked meals?

Do you have someone prepare meals for you?

How often do you eat in restaurants?

Have you ever worked with a nutritionist?

If yes, were you pleased with the results and level of service? Please explain.

Have you ever been on a weight loss program before?

If yes, which one(s)?

What type of eating pattern have you been told you should follow?

When was your diet the most disciplined?

What type of eating pattern did you follow at that time?

What and when did you eat yesterday?

Do you smoke?

If so, how much?

Have you ever done a detoxification diet/cleanse?

If yes which one (s)?

Medical History

List any and all health conditions, medical problems and medications:

List non-prescription drug use: (i.e. Aspirin).

List any recent injuries and/or medical procedures:

Select yes or no to the conditions listed below. If you answer yes to any, it may be necessary to obtain medical clearance before engaging in our exercise program.

Heart attack, coronary bypass or surgery

High blood pressure

Chest discomfort or pain during exertion

Low blood pressure

Frequent Headaches

Heart beat irregularities

Muscular skeletal diseases (i.e. MS, MD, AMS, or Cerebral Palsy)

Vascular disease

Phlebitis, emboli

Shortness of breath, especially during mild exertion

Light headedness or fainting spells

Cardiorespiratory disease (i.e. asthma, bronchitis)

High or Low cholesterol or triglyceride levels

Stroke

Past orthopedic injuries

Recent illness (serious), hospitalization or surgery within past 6 months

If yes, to what degree has the injury been rehabilitated?

Diabetes or other metabolic disorders

Gout

Current pregnancy

Is there a history of cancer in your family?

Has your doctor ever told you that you have a bone, joint or any other orthopedic problem that has been or could be made worse by resistance training?

Would your physician object to your dieting or exercising?

Is there any reason not mentioned on the previous page why you should not follow a regular resistance-training program? If so what is the reason?

For any of the conditions checked above, please list the diagnosis and examining physician.

Examining Physician:

Phone number:

When was your last comprehensive physical examination?

Primary Physician:

Phone Number

Symptoms

Do you have any of the following symptoms? Check all that apply.

If you have ANY of the above symptoms, you may have chemical or heavy metal toxicity. Many of these symptoms can turn into more serious conditions if toxicity is left untreated

Sleep

Average sleep time in hours (weekdays)

Average sleep time in hours (weekends)

Do you sleep restfully?

Do you find it difficult falling asleep or waking up in the morning?

Bowel Health

How often do you have a bowel movement?

How often do you have diarrhea and/or constipation?

How often do you experience gas and/or bloating?

Holistic Care

Do you currently see a chiropractor?

If yes, are you pleased with the results and level of service? Please explain.

Do you currently see an acupuncturist?

If yes, are you pleased with the results and level of service? Please explain.

How often do you get a massage?

Have you ever used a Far-Infrared Sauna?

If yes, please explain.

Have you ever seen a Colonic Therapist?

If yes, please explain.

Have you used other Holistic Modalities?

If yes, please explain.

Date