| Information Requested |
| Physician: | |
| Physician phone number: | |
| Date of birth: |
|
| Height: | |
| Weight: | |
| Do you have any chronic medical problems? Describe. | |
| Have you had any major illnesses in the past? Describe. | |
| Date of last physical examination? |
|
| Please check the cardiovascular risk factors that pertain to you. If you check three or more, please see your doctor before beginning an exercise program. | |
| Do you take any medications? If yes, please list. | |
| Do you have any allergies? If yes, please list: | |
| Occupation: | |
| Weight gain in the last 10 years: | |
| Do you drink 8-12 8oz. glasses of water each day? | |
| Do you limit fats to 20%-30% of total daily calorie intake? | |
| Does your diet include 25g-35g of fiber per day? | |
| Do you have a plan for stress refief? | |
| Do you currently participate in an exercise program? Describe. | |
| Do you have health, fitness, or sports performance goals that we can help you achieve? Please, describe. | |
| I wish to participate in the Montecito Heights Health and Racquet Club fitness programs. I understand that my participation is completely voluntary and that I may withdraw at any time.
These programs are designed to enhance my muscular condition, flexibility, aerobic capacity, body composition and awareness of a healthy lifestyle. There are certain risks involved with any fitness program, which include, overheating, and in some cases, cordiovascular problems. We recommend minimizing these risks by having a physical exam before participating in our programs.
|
I have read this form and understand the information asked of me.
(select all that apply) | |
