New Year, New You

PERSONAL INFORMATION

Name:

Phone#:

Email Address:

Date of Birth:

Sex:

Male

Female

Height:

Weight:

Emergency Contact:

Emergency Contact Phone#:

GENERAL MEDICAL HISTORY

Do you have any chronic medical problems? If yes, please describe:

Have you had any major illnesses in the past? If yes, please describe:

Date of last physical examination:

Do you take any vitamin or mineral supplements? If yes, please list:

Do you take any medications? If yes, please list:

Do you have any allergies? If yes, please list:

HEART HEALTH ASSESSMENT

Please select the cardiovascular risk factors that pertain to you:

LIFESTYLE ASSESSMENT

Occupation:

Weight gain in the last 10 years:

Do you drink 8-12 (8oz) glasses of water per day?:

Yes

Not Sure

Do you limit fats to 20-30% of total daily calorie intake?:

Yes

Not Sure

Does your diet include 25-35 grams of fiber per day?:

Yes

Not Sure

Do you limit your intake of alcohol, caffeine, sugar and salt?:

Yes

Not Sure

Do you currently participate in an exercise program? If yes, please describe:

Why have you decided to become more active? Do you have health, fitness or sports performance goals we can help you achieve?:

I understand that my participation is completely voluntary and I may withdraw at any time: *

Yes

The Studios at Montecito Heights