Answer the following questions to
the best of your knowledge. When
you have completed the profile
follow the instructions below. We
hope you score Healthy. |
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Is this your first time taking this survey?
Yes
No |
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*First Name |
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*Last Name |
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*Email
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Sex |
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Race / Ethnicity |
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Age |
Previously: |
*Weight |
Previously: |
*Height - Feet |
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*Height - Inches |
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1. Has your doctor said that you have a heart problem?
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Yes
No |
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2. Do you ever have any pains in your heart or chest?
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Yes
No |
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3. Do you ever feel faint or have episodes of dizziness?
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Yes
No |
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4. Have you ever been told that you have high blood
pressure?
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Yes
No |
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5. Is there a history of heart disease in your family?
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Yes
No |
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6. Do you know your cholesterol level?
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Yes
No |
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7. Do you have any bone, joint, or muscle problems that could be aggravated by exercise or activity?
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Yes
No |
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8. Have you ever been diagnosed with asthma? List any and all medical conditions that could be aggravated by exercise?
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Yes
No |
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9. Have you ever been diagnosed with diabetes?
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Yes
No |
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10. How many days per week are you involved in cardio/aerobic activity?
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1
2
3
4
5
6
7
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11. Check each activity below that you regularly incorporate into your exercise program.
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Biking Indoor or Outdoor
Treadmill
Stair Climber
Elliptical
Aerobics Classes
Running
Walking
Swimming
Organized Sports
Rowing
Interval Training
None
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12. How long does each aerobic session usually last?
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0-18 min.
19-35 min.
36-60 min.
Over 60 Min.
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13. How many days per week are you involved in weight resistance exercise?
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0
1
2
3
4
5
6
7
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14. Which best describes your past exercise and activity history.
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No Activity
Somewhat active
Very Active most days
Active and exercised my entire life |
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15. Which best describes you overall nutritional habits?
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Eat anything I want.
I have made some changes in my eating habits.
I am very aware of my nutritional choices.
I am totally dedicated to proper nutrition. |
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16. A dim light or slight noise will wake me at night.
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Always
Sometimes
Never |
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17. I seem to be gaining weight around my stomach.
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A lot
Not much
No weight gain
Losing weight currently |
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18. I push for doing things my way.
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Always
Sometimes
Never |
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19. When completing a task, I can say, that I am satisfied with what I did.
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Almost never
Sometimes
Frequently |
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20. At the end of my workday, I am very tired.
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A lot
Sometimes
Never |
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21. Are you interested in Personal Training?
Yes
No
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* I understand that I have answered these questions to the best of my ability and my answers are a true representation of my current health and fitness levels. I understand that my exercise and activity habits may change upon taking this survey, and that I may be contacted by a representative of MAC. LLC who will make suggestions to improve my overall fitness and activity levels. I acknowledge and fully understand the exercises in which I will be engaging and the risks and benefits which may result thereof. I, also hereby, for myself, my heirs, executors, and administrators, waive and release any and all rights and claims for damages I may have against Mac, LLC, or their respective agents, representatives, successors, and assigns for any injuries which may be suffered by me in connection with my participation in any exercise or fitness center related activity.
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I Agree |
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How did you hear about us? |
Internet
Mail Flyer
Friend
Brochure
TV
Radio |
Other
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Opt into our mailing list
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No |
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Additional Comments or Questions |
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*
= required fields |
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