PHYSICAL HISTORY

Name
Email
Rate yourself on a scale of 1 to 5 (less to more). Pick the number that applies the most.
Rate your level of participation in fitness for the age range of 15 to 20 years
Rate your level of participation in fitness for the age range of 21 to 30 years
Rate your level of participation in fitness for the age range of 31 to 40 years
Rate your level of participation in fitness for the age range of 41 to 50 years
Rate your level of participation in fitness for the age range of 50+ years
Characterize your present athletic ability.
When you exercise, how important Is competition?
Characterize your present cardiovascular capacity.
Characterize your present muscular/strength capacity
Characterize your present flexibility capacity.
Where you a high school and/or college athlete? If so, please indicate which sport(s) you played and at level in the box below.
Do you start exercise programs but then find yourself unable to stick with them?
Yes No
How much time are you willing to devote to an exercise program?
Minutes/Day
Days/Week
Can you exercise during your work day?
Yes No
Would an exercise program interfere with your job or other responsibilities?
Yes No
Describe your current exercise routine(s)
Rate your perception of the intensity of your exercise routines
Light Fairly Light Somewhat Hard Hard
What are your hobbies and interest?
Would you participate in organized activities?
Mountain Biking (Day Trip) Hiking (Day Trip) Softball
Running Races Group Exercise Class Other