The following questions are meant to give us a general overview of your current and past physical health which will aid in building a personalized health/fitness program designed specifically for you. 

   **This form is to be submitted before using Totally Sound Fitness, Inc.'s services.

Please Note:  All information is confidential and used only by Totally Sound Fitness, Inc to assist in building a personalized health and fitness program.  See Privacy Statement

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First Name*   Last Name*   Home Phone* (000-000-0000)   Work/Alternate Phone   Sex*   Age*   Emergency Contact Person*   Phone*   Email*   Cardio-Respiratory History Heart disease now? No Yes Fainting? No Yes Heart disease in the past? No Yes Asthma? No Yes Heart murmurs or prolapsed? No Yes Shortness of breath with exercise? No Yes Mitral value No Yes Allergies, on medication? No Yes Please explain Yes answers: Coronary Risk Factors (check any that apply) History of high blood pressure - Current Blood Pressure Elevated total cholesterol - Current Level Cigarette smoking - Past    Present           #Daily Abnormal EKG   Family history of heart disease                  Relation to you Diabetes - Family    Self   Insulin Dependent   Over weight  - Number of pounds over your ideal weight Muscular History Current muscle injuries No Yes Past muscle injuries No Yes Muscular weakness now No Yes Pain with exercise No Yes Bone-Joint History Diagnosed with osteoporosis or lost height? No Yes     Joint replacement? No Yes Which joints? Current bone or joint injuries/illness? No Yes     Past bone or joint injuries/illness? No Yes     Arthritis pain? No Yes     Knee weakness, injury, surgery No Yes Which knee? Back pain No Yes     Please explain Yes answers: Have you been diagnosed with: Disk injury? No Yes Nerve Injury? No Yes Arthritis in the spine? No Yes Please explain Yes answers: Pregnancy or postpartum? Recent surgeries (within 12 months) Do you have a medical condition or symptoms not mentioned previously? List medications you are taking and what condition each is for Medication Condition What regular physical activity do you do? How often? Enter CAPTCHA Anti Spam validation to continue *