Please fill out the following form to better help us begin your Fitness Assessment.

Items with an *are required information.

*Name:        *Phone 1  Phone 2

Company:         

 *Address:

 *City           *State               *Zip Code

 

*Email Address:

 

Do you own any fitness equipment? Yes      No

 

If yes, please describe:

 

When is the best time to reach you on Phone 1*      Phone 2*

 

How did you hear about Bee Strong Fitness?

 

Please name three days and times you are available for your free assessment:

*Day 1   *Time

*Day 2   *Time

*Day 3   *Time

 

 

Assessment location (if different from address above):

 

Please answer the following questions to the best of your ability:

Goals:

Short Term (2-3 weeks):        

Moderate term (3-6 months):

Long Term (1-3 years):         

When was your last physical examination? 

Has one or more of your close family members been diagnosed with coronary heart disease (CHD), high blood pressure/hypertension, suffered a stroke, diagnosed with diabetes mellitus?                    Yes                No

Daily Activity Level:                  Sedentary             Moderately Active                 Very Active

 

Are you on any Medications  Yes No

If Yes Please List  

 

Check all that apply:

           Male age 40 or above

            Female age 50 or above

            Pregnant

            More than 20 lbs overweight

            Tobacco use

 

Check if yes:

            Have you been seen by a physician in the last 12 months?

            Are you currently cleared by a physician to exercise?

            Are you between the ages of 18 and 40 and in good health?

 

Are you currently experiencing any of the following?

            Common cold/influenza

            Fever/infection/vomiting

            Recent surgery/wound

            Fracture/dislocation/sprain

            Pneumonia/hacking cough

            Other recent physical problem

            Currently on medications

 

Have your ever experienced the following? Check All that Apply

             Pain of any kind, including chest pain or numbness

             Fainting/dizziness

             Allergic reaction to exercise

             Cancer

             Heart disease

             Stroke

             Heart attack

             High blood pressure/ with no medications

             High blood pressure/ with medications

             Pulmonary disease

             Asthma

             Shortness of breath climbing stairs

             Type 1 Diabetes (insulin dependent)

             Type 2 Diabetes (non-insulin dependent)

             Seizure/epilepsy

             Arthritis/joint problems

             Low back pain

 

Cardiovascular exercise questions:

 

            1) How often do you exercise?

                        Never (skip #4)

                        1-3 days per week

                        4 or more days per week

 

            2) When you perform cardiovascular exercise, how long do you participate?

                        Less than 10 min/ exercise session

                        20-40 min/exercise session

                        Longer than 40 min/exercise session

 

            3) When you perform cardiovascular exercise, do you experience?

                         Severe shortness of breath

                         Moderate shortness of breath

                         Mild shortness of breath

 

Muscle conditioning questions:

 

            4) Do you include weight training in your regular workout?

                         No (skip to #8)

                         Yes

 

            5) If yes, how many days per week?

                         Less than 2

                         2-3

                         More than 3

 

            6) How long is your weight training exercise on average?

                        Less than 15 min per session

                        15-30 min per session

                        Longer than 30 min

 

            7) Is your training method:

                        High reps – Low weight

                        Low reps – High weight

 

            8) Do you include flexibility stretching after your workout sessions?

                         Yes, 3 or more times per week

                         Yes, 1-2 times per week

                         No

 

            9) Select one of the following activities for your cardiovascular exercise:

                         Walking

                         Walk/jog

                         Running

                         Cycling

                         Stair climber

                         Group exercise – including low impact step and kickboxing

                         Swimming