MPF Health History Survey
What is your first and last name?
Answer:
Required
What is your email address?
Answer:
Required
Check any of the conditions described below which you have, or have had in the past.
Coronary Heart Disease
Diabetes (Type 1 or Type 2)
Stroke
Peripheral Vascular Disease
Phlebitis or Emboli
Rheumatic Fever
High Blood Pressure
Low Blood Pressure
Chest Pain or Discomfort
Heart Murmur
Ankle Swellings
Migraines
Swollen, Stiff, or Painful Joints
Foot Problems
Back Problems
Neck Problems
Fractures or Broken Bones
Cold Hands or Feet
Light-Headedness or Fainting
Epilepsy or Seizures
Anemia
Asthma
Emphysema
Bronchitis
Pneumonia
Ulcers
Hernia
Arthritis
Bursitis
Stomach or Intestinal Problems
Osteoporosis
Allergies
Required
If you checked any of the above, please explain here.
Answer:
Required
List any prescription medications you are taking.
Answer:
Required
List any over-the-counter medications or dietary supplements that you are taking.
Answer:
Required
List any illnesses, hospitalizations, or surgical procedures you have had within the last 5 years.
Answer:
Required
If you were involved in exercise or sports in the past, please describe the activity, its intensity and duration.
Answer:
Required
How would you describe yourself today?
Sedentary/Inactive
Lightly Active
Moderately Active
Highly Active
Required
How would you describe your nutrition habits?
Poor
Fair
Good
Excellent
Required
Describe your knowledge of exercise and fitness.
Poor
Fair
Good
Excellent
Required
Describe your knowledge of nutrition.
Poor
Fair
Good
Excellent
Required
Do you consume alcohol?
Yes
No
Required
If you checked yes, how much alcohol do you consume?
Answer:
Optional
Do you currently smoke, or have you ever smoked
Yes
No
Required
If you previously smoked, how long did you smoke?
Answer:
Optional
How often did you smoke before you quit?
Answer:
Optional
When did you quit smoking?
Answer:
Optional
If you currently smoke, how often do you smoke?
Answer:
Optional
If you currently smoke, how much do you smoke?
Answer:
Optional
Do you consider yourself under-weight or over-weight?
Overweight
Underweight
Neither
Required
How many meals do you eat each day?
Answer:
Required
Check any of the fitness goals described below which you wish to achieve.
Improve Strength
Improve Flexibility
Improve Cardiovascular Fitness
Improve Muscle Tone and Shape
Improve Diet/Eating Habits
Lose Weight
Improve Muscular Endurance
Reduce Stress
Increase Strength
Stop Smoking/Drinking
Injury Prevention
Rehabilitate Injury
Gain Weight/Muscle
Required
What is your main purpose for applying to MPF Training Systems? (Please be very clear.)
Answer:
Required
Are there any other final comments you may wish to add to this questionnaire?
Answer:
Required
I give permission for my child’s photo to be used in any promotional material, such as a brochure, website or newspaper advertisement, only for the purpose of promoting MPF Training Systems. I give permission for my child to be videotaped for the purpose of testing my child’s athletic abilities. My child’s video tape may be used to promote MPF Training Systems or teaching coaches and/or fitness professionals athletic movement.
I agree
I disagree
Required
I hereby state that I have, to the best of my knowledge, given an accurate report on my medical, fitness, and health history.
I agree
I disagree
Required
Submit!
