Carole & Marcus Weinstein Jewish Community Center
    Client Health and Fitness Profile

Personal Information

Name: ________________________________________________________________________________________________

Address: ______________________________________________________________________________________________

City, State & Zip: ______________________________________________________________________________________

Telephone: (H)____________________________________  (W/CELL)__________________________________________

Occupation:___________________________________________________________________________________________

Sex: __________________   Date of birth: _____________________________________  Age: ___________________

Email:____________________________________________________________

Please circle all that apply to you: 

Moderate/High Blood pressure		High Cholesterol			Diabetes

Arthritis					Osteoporosis			Currently Pregnant

Cancer					Stroke				Heart Disease

Heart Attack				Heart Murmur			Insomnia				

High Stress				Emphysema			Migraines

Asthma					Varicose Veins			Back Pain

Family History:
Has anyone in your immediate family been diagnosed with any of the following before the age of 65
     
     Disease			Yes/No					Family Member

1) Diabetes	_________________________________           _______________________________________________

2) Heart Disease _________________________________           _______________________________________________

3) Hypertension _________________________________	     _______________________________________________

4) Stroke            _________________________________	     _______________________________________________

5)  Obesity         _________________________________	     _______________________________________________	

1) When was the last time you had a physical examination? ______________________________________________________

2)  Have you had any recent injuries or surgeries? ______________________________________________________________________________________________________

______________________________________________________________________________________________________

3)  Do you have any other chronic or serious illnesses? Please list ______________________________________________________________________________________________________

______________________________________________________________________________________________________

4)  Do you have any joint or muscle issues? Please list ______________________________________________________________________________________________________

______________________________________________________________________________________________________

5)  Are you currently taking any medications? Please list  
______________________________________________________________________________________________________

______________________________________________________________________________________________________

Dietary Habits

1)  What is your current weight?  ________________lb         height? _______________in.

2)  What would you like to weigh?  _______________lb

3) Have you been on weight control or weight loss programs in the past? _________________ if so, what types and did they work for you?
____________________________________________________________________________________________________________________________________________________________________________________________________________

4)  Which of the following do you eat regularly?  Circle the ones that apply

        Breakfast	                                        Midmorning snack	                                            Lunch	     

Midafternoon snack	                                    Dinner 	                                                 After-dinner snack

5)  How often do you eat out? ____________________________________________________times per week

6)  Describe your typical portions at a meal.  Small, Medium, Large, Extra large, or unsure
____________________________________________________________________________________________________________________________________________________________________________________________________________

7)  Do you often eat more than one serving?   _________________________

8)  How long does it usually take you to eat a meal?  ________________________ minutes

9)  Types of snacking, how many times per week do you eat the following?

	Cookies, cake, pie__________________	Candy_______________________	 Diet soda______________________
	Soft Drinks_______________________       Fruit/Vegetables _________________________
               Milk or milk beverage______________       Potato chips, pretzels, etc. ____________________
               Peanuts or other nuts_______________  	Ice Cream_____________________________
              Cheese and crackers_______________         Other______________________________

10)  Do you eat fried foods?  __________________ if so, how many times per week/month and what types ____________________________________________________________________________________________________________________________________________________________________________________________________________

11)  Do you salt your food?  _________________________
       
12)  How much water do you drink per day (# of 8oz glasses)? ___________________________________________________

13)  Do you consume any of the following per/day:  Cups of coffee ______________if yes, how many ____________per day
Drinking Habits:  On average how many of the following do you consume a week?
					
Beer ______________________________ glasses or cans
					
					Wine ______________________________ glasses
	
					Other ______________________________ glasses

Smoking Habits:  

1)  Have you ever smoked cigarettes, cigars, or a pipe?  		Yes 		or 		No

2)  Do you smoke presently?  					Yes		or		No

3)  At what age did you begin smoking? _______________________________________ years

4)  If you have quit smoking, when did you quit? ___________________________________________________________

5)  Does anyone else in your immediate family/ or whom you live with smoke? ____________________________________

Exercise Habits:  

1)  Are you currently exercising? 			Yes 		or 		No
      
If yes; How often (frequency)?  How long (duration)?  What intensity?  And What types?  ____________________________________________________________________________________________________________________________________________________________________________________________________________

2)  How many days per week do you plan on exercising and at what intensity?  ______________________________________________________________________________________________________

3)  How would you describe your level of daily activities?  

___________ Light (office work)   ____________ Moderate (factory worker)__________ Heavy (construction worker)

4) Circle all activities you would choose to include in your exercise program.

    Walking, running, or jogging outside			Treadmill

         Crosstrainer/Elliptical				Bicycling       outside    or     inside	  or   both

                Steppers					Rowing machines

                 Step classes					Cycling classes

                     Yoga					Pilates

                     Dance					Group exercise classes (general)

                 Basketball					Swimming

                   Tennis					Recreational Activities (hiking, climbing, kayaking etc.)

	Weight training

WAIVER

I understand if I experience any pain or discomfort during this session, I will immediately inform the trainer so the weight or cardio equipment may be adjusted to my level of comfort.  I understand that participating in any program of exercise, nutrition and lifestyle change has certain risks.   I affirm I have stated all my known medical conditions, and answered all embarking on such a program.  I also acknowledge that all participants in any program should consult their physician before embarking on such a program.  I take full responsibility for my participation in any of these programs and for any claims of injuries or illness that may result from my participation in any of their programs.   

The undersigned agrees that all activities shall be undertaken at his/her sole risk and that the Carole & Marcus Weinstein Jewish Community Center shall not be liable for any injuries, damages, or loss of property arising from his/her use of the center, now or in the future.  

Please give at least a 24 hour notice if you cannot keep your appointment. 

Signature ____________________________________________________
Date __________________________________________