Name: Age: Weight: Height: M F

Address: City:  State: Zip:

Email: Phone 1: Phone 2:

Emergency Contact: Phone: Relation:

Current Injuries:

Prior Surgeries:

Medications:

___________________________________________________________________ 
Please Indicate any of the following for which you
have been diagnosed or treated by a health professional:

Which of the following best describes you?

Any of these health symptoms that occur frequently is the basis for medical attention. 
Circle the number indicating how often you have each of the following:

5 = Very Often;  4 = Fairly Often;  3 = Sometimes;  2 = Infrequently;  1 = Practically Never

ACMS Health Status Questionnaire: 
Please indicate “yes” or “no” for each of the following questions:

Yes No 1.Do you have any personal history of heart disease?

Yes No 2.Do you have any personal history of metabolic disease 
                    (thryoid, renal, liver)?

Yes No 3.Do you have Diabetes

Yes No 4.Have you experienced pain or discomfort in your chest 
                    due to deficient blood flow?

yes No 5.Have you had any unaccustomed shortness of breath?

Yes No 6.Have you had any problems with dizziness or fainting?

Yes No 7.Do you have difficulty breathing while standing or sudden 
                    breathing problems at night?

Yes No 8.Do you suffer from ankle edema (swelling of the ankles)?

Yes No 9.Have you experienced a rapid throbbing or fluttering of the heart?

Yes No 10.Have you experienced severe pain in legs muscles during walking?

Yes No 11.Do you have a known heart murmur?

Yes No 12.Do you have any family history of cardioac or pulmonary disease 
                      prior to age 55?

Yes No 13.Have you been assessed as hypertensive on at least 2 occasions?

Yes No 14.Has your serum cholesterol been measured at greater than 
                      240 mg/dl?

Yes No 15.Has your HDL (the "good" cholesterol) been measured at greater 
                      than 60 mg/dl?

Yes No 16.Are you a cigaretter Smoker?

Yes No 17.Would you characterize your lifestyle as "sedentary"?

Yes No 18.Is your doctor currently prescribing drugs for a blood pressure 
                      or heart condition?

Yes No 19.Do you exercise regularly?

Yes No 20.Do you know of any reason why you should not do physical activity?

_____________________________________________________________________
How many days per week do you accumulate 30 minutes of moderate activity?:

How many days per week do you normally spend at least 20 minutes in vigorous exercise?:

Any additional health related information that is relevant to completing an exercise routine safely, please describe them here:

Weekly Exercise Information:

Explain what types of resistance exercises, cardiovascular
activities you perform on average during a 7-day period.           

Exercise/Activity:    Days/Week:   Duration:  

Exercise/Activity:    Days/Week:   Duration:  

Exercise/Activity:    Days/Week:   Duration:  

Please list foods that you enjoy (Fill your shopping cart with this list)

 Please list foods that you do not enjoy (Foods you will not eat or prepare)

Please list any allergies to Medication, Foods, or any other Allergens

Please indicate your personal health and fitness goals

The information provided on this health status questionnaire is accurate and complete to the best of my knowledge. I understand the purpose of this evaluation and consent to it being viewed by the Personal Trainers at Mobile Metabolics only. I also understand that any false or withheld information may result in an erroneous exercise routine that could be detrimental to my own health
                                                                           (Initials Here):