fitness assessment Name * First Name Last Name Email * Preferred learning and communication style? (written, verbal, visual, etc.) * How would you rate your current pain level? 0-no pain 1 2-mild pain 3 4-moderate 5 6-severe 7 8-very severe 9 10-worst pain possible Lifestyle & Goals What is your primary fitness goal? Please select all that apply. * Overall Fitness Lose Weight/Body Fat Gain Weight/Muscle Increase Muscular Strength Increase Cardiovascular Endurance Improve Sport Performance Body Building (competitive) Improve Balance Decrease Stress Manage Chronic Health Condition Other Other. Please describe What is your timeline for goal completion? Please explain. * Are you currently involved in a regular aerobic exercise program such as walking, jogging, cycling, swimming, step aerobics, etc.? * Yes No Are you currently participating in weight training? * Yes No Do you perform exercises on a regular basis? * Yes No Are you performing a consistent warmup/cooldown ? Please explain how long and what types. * How often does your schedule allow you to exercise or go to the gym? Hours per week * How many minutes per day can you devote to your workout? * What is your current occupation? * Does it require any of the following: extended periods of sitting, standing, or repetitive movements? Please describe. * Do you have difficulty with any of the following? Please select all that apply. * Picking up a small child Carrying a 10lb bag of groceries Performing household chores (vacuuming, mopping, washing windows) Climbing a flight of stairs Walking without assistance (cane, walker, etc.) Opening a jar of food Getting in and out of the bathtub Rising from the couch or low chair without using your arms for assistance Placing or retrieving objects from overhead Tendency towards muscle strains and/or sprains Other Other. Please describe. Do you have any concerns with nutrition or proper hydration? * How are your sleeping patterns? Please describe * Medical History Have you ever been diagnosed with any of the following conditions? Please check all that apply. * History of heart problems, chest pain or stroke (including uncontrolled rhythm) Uncontrolled blood pressure (high or low) High cholesterol Circulation problems Lung conditions (asthma, pneumonia) COPD ( emphysema/chronic bronchitis) Infectious disease (hepatitis, AIDS, STD) Anemia Seizure activity Tobacco use Thyroid Problems Diabetes Obesity Neuromuscular disease (MS, ALS, MD) Rheumatoid arthritis Osteoarthritis Stroke or TIa Kidney disease Hernia Mental disorders (clinical depression, PTSD) Currently have draining or infected wound/rash Currently pregnant or post partum Other Other. Please describe. Are you currently taking any medications? Please describe. prescription as well as any supplements/vitamins. * Do you currently have any pain or injuries (neck, ankle, back hip, shoulder, etc.)? Please explain. * Do you have any relevant family health history or concerns? Please describe if any. * Thank you!