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Fitness Triage™
Please check off all items that apply to your health and disease status. Your answers will be used to assess your exercise risks and provide you with specific fitness and exercise information.
CHECK ALL THAT APPLY
Male age 40 or above
Female age 50 or above
Pregnant
More than 20 pounds overweight
Tobacco use
CHECK IF YES
Have you been seen by a physician within the last 12 months?
Are you 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 YOU EVER EXPERIENCED ANY OF THE FOLLOWING?
Pain of any kind, including chest pain or numbness
Fainting/dizziness
Allergic reaction to exercise
Cancer
Heart disease
Stroke
Previous heart attack
High blood pressure/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 problem
Low back pain
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Personal Trainer and Group Exercise
Fitness Triage®, TeleFitness®, Nutrition Gets Personal™,
Exercise Gets Personal™ and Fitness Gets Personal®
are protected by U.S. patent.
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