ExRx Fitness Program Questionnaire Thank you for ordering your 30 day Consultation & Program Design from ExRx. Please fill out this form so we can design your personalized fitness program. The information on this form will go directly to ExRx.net. All information is considered confidential and will only be used for the purposes of designing your fitness program. ExRx will send your personalized fitness program to your e-mail with in 3 business days. Contact information: Customer order number First name Last name Street address Address (cont.) City State/Province Zip/Postal code Country Home Phone E-mail Other information: Age Sex Male Female Height Weight Are you pregnant? Yes    No   Do you have any orthopedic problems or injuries (joint, ligament, tendon, bone, or muscle). If yes, be specific and include any exercises or movements that cause pain or irritation. List any medical conditions you have. This may include, but is not limited to high blood pressure, elevated blood cholesterol, diabetes, thyroid condition, hernia, asthma, etc. Please list the names of any medications you use. Has a physician ever said you should restrict your physical activity? Yes    No     If yes, explain: Do you smoke tobacco products? Yes    No     If yes, how much?  Enter your occupation in the space provided below. Rate your overall activity level? Sedentary Moderately active Active Very active What exercise, if any, do you currently do? What exercise, if any, have you done in the past? How long ago? If you currently weight train, please list the exercises you have regularly performed in the last month. What is your current cardiovascular fitness level, or your ability to perform aerobic exercise like cycling, brisk walking, jogging, etc.? Very low Fair Average Good Excellent How would you rate your experience with exercise? Beginner Intermediate Advanced Do you exercise regularly? I have never exercised regularly I am currently starting back on a program, I used to exercised regularly. I am currently exercise regularly What are your fitness goals? (check all that apply): Appearance (aesthetics) Cardiovascular endurance Fat reduction Flexibility Health (General) Muscular definition Muscular endurance Muscular size Muscular strength Power Self-esteem or confidence Speed Sports performance Stress reduction Toning and shaping Weight loss Posture Other Please explain your perceived benefits or objectives the behind your goals. List any other specific fitness goals (eg: run 5K, get back into your old jeans, play soccer with your kids, etc.) Measurements (optional): Neck Chest Arm Forearm Waist Hips Thigh Calf Please list problem body parts (specify over fat, over or under developed). Please type how much total time you can devote to exercise each day. For significant results include at least 3-4 days per week for at least 30 minutes, for optimal results include 5-6 days a week.  If there are specific days you like to have off, please do not put down your availability for those days. Sunday Monday Tuesday Wednesday Thursday Friday Saturday Please list other physical activities you will be engaging in addition to this program (soccer practice, basketball league, etc.): Where do you intend to exercise (check all that apply)? Fitness facility (gym or health club) Home Outside What equipment do you have available (check all that apply)? Nothing Free weights Weight machines Resistance Tubes (rubber tubes with handles) Cardio equipment Bicycle (outdoor) Aerobic videos (step, low impact, kickboxing) Please note any other information regarding available equipment you feel would be helpful in designing your program: What types of activities would you like to have included on your fitness plan (check all that apply)? No strong preferences, make recommendation based upon my goals and available equipment Resistance Training Free weights Weight machines Calisthenics (body weight against gravity) Resistance tubes Cardio Training Brisk walking Jogging Running Hiking Aerobic classes Bicycling (outdoors) Stationary cycle Stair climbing machine Elliptical trainer Airwalker Health rider Rowing machine Swimming Flexibility Training Stretches Athletic Performance (not recommended for beginners) Sprinting and speed training Plyometrics Olympic style lifts Please list other activities you would like to be included in your fitness program (rollerblading, sprinting stairs, etc.). Select your personal obstacles in adhering to an exercise program (your reasons for not exercising or dropping out of past programs): I feel intimidated or embarrassed in an exercise setting Upcoming holidays or planned vacation may make it difficult to fit in exercise I travel extensively for work or fun Work demands may make it difficult to exercise I don't know how I'm going to find the time to exercise I might get frustrated if I don't see results right away Family obligations may make it difficult to exercise My family or friends may not support my attempts to exercise Exercise is not enjoyable or fun for me I get bored easily when I exercise It's hard for me to exercise when I'm tired or fatigued I may forget or lose track of my goal I may have to exercise alone The exercise setting available to me may not meet my needs I don't enjoy exercising in bad weather (rainy, hot, humid, cold, snow) I have no personal obstacles in adhering to an exercise program What are your specific expectations of your fitness program during the next 4 weeks? Description of your eating habits for a typical day (optional: include what you eat, drink, amounts, times, etc.) Any other information you feel may apply?

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