Client Information Step 1 of 2 50% PART I. PERSONAL INFORMATIONName* First Last Address* Street Address City State / Province / Region ZIP Email* Phone*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Sex*MaleFemaleEmergency Contact* First Last Emergency Contact Phone*Relationship*Personal Physician*Physician Phone* PART II. HEALTH QUESTIONNAIRE1. Has a doctor ever said that you have any of the following?Heart ProblemsStrokeEpilepsyDiabetesHypertensionCancerChronic Infectious DiseasesHerniaMetabolic DiseasePeripheral Vascular DiseaseRecent InfectionStomach or Intestinal ProblemsOther (explain)Please Explain Other From Above:2. Do you have any of the following?Back ProblemsJoint, Tendon, or Muscular PainLung DiseaseOther (explain)Please Explain Other From Above:3. Please list any medications you are taking.(name & reason)4. Do you have any medical conditions for which a physician has ever recommended some restrictions on activity (including surgery)?NoYesPlease Explain5. Has anyone in your immediate family (father, mother, brother, or sister) had a heart attack or other heart-related problems before the age of 50?NoYesPlease Explain6. Are you pregnant?NoYesWhat Trimester?7. Do you smoke?NoYesProvide number of cigarettes, cigars, or pipes per day.8. Do you drink alcoholic beverages?NoYesHow many per week?Note: One drink equals 7 once of hard liquor, 6 ounces of wine, or 72 ounces of beer 9. Are you presently exercising a minimum of 2 times per week for at least 20 minutes at a time?NoYesIf yes, please specify:Total minutes engaged in aerobic activity per week?40-60 minutes/week61-80 minutes/week81-100 minutes/week100+ minutes/weekDegree of exertion (effort)?LightMediumHardBy providing my full name (First Middle Last) in to the field below, I acknowledge that the information I have provided above is accurate. Typing your name here serves as you legal signature.*Date*