| |
|
|
|
|
| 1. |
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? |
|
|
No
|
| |
|
|
|
|
| 2. |
Do you feel pain in your chest when you perform physical activity? |
|
|
No
|
|
| 3. |
In the past month, have you had chest pain when you were not performing any physical activity? |
|
|
No
|
|
| 4. |
Do you lose your balance because of dizziness or do you ever lose consciousness? |
|
|
No
|
|
| 5. |
Do you have a bone or joint problem that could be made worse by a change in your physical activity? |
|
|
No
|
|
| 6. |
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? |
|
|
No
|
|
| 7. |
Do you know of any other reason why you should not engage in physical activity? |
|
|
No
|
| |
|
|
|
|
| |
|
|
|
|
| If you have answered yes to one or more of the above questions, please consult your physician before engaging in physical activity and tell your physician which questions to which you answered yes. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. |
| |
|
|
|
|
| General |
|
| |
Occupation |
|
|
|
| |
|
|
|
|
| 1. |
What is your current occupation? |
|
|
No
|
|
| 2. |
Does your occupation require extended periods of sitting?
(If yes, please explain.) |
|
|
No
|
|
|
| 3. |
Does your occupation require extended periods of repetitive movements? |
|
|
No
|
|
| 4. |
Does your occupation require you to wear shoes with a heel (dress shoes, high heels, etc.)? |
|
|
No
|
|
| 5. |
Does your occupation cause you anxiety or mental stress? |
|
|
No
|
| |
|
|
|
|
| |
Recreation |
|
|
|
| 6. |
Do you participate in any recreational activities (golf, tennis, skiing, etc.)?
(If yes, please explain.)
|
|
|
No
|
|
|
| 7. |
Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)?
(If yes, please explain.) |
|
|
No
|
|
| |
|
|
|
|
| |
Medical |
|
|
|
| 8. |
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?
(If yes, please explain.) |
|
|
No
|
|
|
| 9. |
Have you ever had any surgeries?
(If yes, please explain.)
|
|
|
No
|
|
|
| 10. |
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes?
(If yes, please explain.) |
|
|
No
|
|
|
| 11. |
Are you currently taking any medication?
(If yes, please List.) |
|
|
No
|
|
|
| 12. |
Do you have doctor’s permission to begin an exercise program?
(If yes, please explain.)
|
|
|
No
|
|
|
| 13. |
Do you have any medical conditions that would prevent you from beginning an exercise program?
(If yes, please explain.)
|
|
|
No
|
|
|
| 14. |
Do you agree to contact Ryan Joseph before your next session begins if your medical condition changes.
(If yes, please explain.)
|
|
|
No
|
|
| |
|
|
|
|
| |
Motivation |
|
|
|
| 1. |
Please describe the best time of your life physically and how it made you feel.
(In a few sentences.) |
|
|
| |
|
|
|
|
| 2. |
Please describe what you feel being in shape is going to do for you.
(In a few sentences.) |
|
|
| |
|
|
|
|
| 3. |
Please describe 5 activities you will continue to do once you reach your goal.
(In a few sentences.) |
|
|
| |
|
|
|
|
| 4. |
Imagine what it will be like a year after you have achieved your goal. Describe in a few sentences how wellness and vibrant health feels in your life and what you are able to accomplish NOW.
(In a few sentences.) |
|
|
| |
|
|
|
|
| 5. |
List three people that said you cannot get into shape or reach your goals.
(In a few sentences.) |
|
|
| |
|
|
|
|
| |
|
|
|
|
