Please print out this section and fill it out on paper.  You can also choose select all under edit, copy it, paste it into an email, answer the questions and email them to me. Answer your questions in all capital letters or highlight your answer some way.

Exercise History

I need the details of your exercise routine now.  What exercises do you do?   How often do you do it?  How intense is the effort of exercise?  How long does a usual period of exercise last?

{Intensity is how hard you perceive the work.  If you walk and can talk to your partner easily, that effort on a 1-10 scale with 10 most difficult might be a 4.  If you can only say a few phrases that might be a 6.  If you can’t talk at all except for a quick word or two that would be 8 or more}

 Examples of types of exercise:

Walking,  Exercise class for 50 minutes, lifting weights with 3 minutes between sets or fewer minutes between sets, running, treadmill with variation in speed and incline, a session at Curves, Pilates class - beginner, intermediate, advanced levels.  You get the idea.

Tell me what you have done the past 3 months, past year and past 5-10 years.

Do you get exercise in other ways in your life?  Yard work, cutting wood, house work, gardening

Fitness/Wellness Goals

1. What would you like do in the next 3 months?

2.  How about more than 3 months from now?

3. What other activities interest you in addition to those you listed above?

Examples would be treadmill, Outdoor Running, Stationary Bike, Outdoor Cycling, Rollerblades, Aquatics, Aerobics, Elliptical, Pilates, Yoga, Flexibility, Resistance Training, Others???

How Much Time would you like to dedicate to your physical activity?  Days per week?____  Time per day in minutes____

Your Physical  Stats

Height___  Weight_____  Your ideal weight______

Least you have weighed as an adult and when__________

Most you have weighed as an adult and when__________

Circumferences (inches)

Waist___      Bicep (R)_____  Thigh(R)______ Calf(R)_____

Hip ____      Neck  _______

 Rest Heart Rate (BPM) ______

Resting Blood Pressure ___/____

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