Name *

First Name

Last Name

Birthday

MM

DD

YYYY

Phone Number *

(###)

###

####

How many hours do you work per week?

<35

35-40

40-45

45-50

>50

What are your primary physical requirements of your job?

Phone/computer

Sitting

Standing

Lifting

Travel

Emergency Contact *

First Name

Last Name

Phone Number *

(###)

###

####

Please indicate if YOU have any following conditions: *

Asthma

Arthritis

Cancer

Diabetes

Hypertension

Heart Disease

High Cholesterol

Osteoporosis

Obesity

Stroke

Other

NONE

Please indicate if you have any PRIMARY RELATIVES with the following conditions: *

Primary relative = parent, grandparent, sibling, child

Asthma

Arthritis

Cancer

Diabetes

Hypertension

Heart Disease

High Cholesterol

Osteoporosis

Obesity

Stroke

Other

NONE

NOT SURE

Please indicate if you have had any past injuries or surgeries that may limit or affect your ability to exercise *

Neck

Shoulder

Elbow

Wrist/Hand

Hip

Knee

Low Back

Ankle/Foot

Other

NONE

Do you or have you smoked cigarettes?

Yes, and currently smoke

Yes, but I quit smoking

Very rarely

No

Do you drink alcoholic beverages?

Yes

No

Are you currently on a diet or weight control program?

Yes

No