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.
Is this your first time taking this survey? Yes No
*First Name
*Last Name
Race / Ethnicity
Age   Previously: 
*Weight   Previously: 
*Height - Feet
*Height - Inches
1. Has your doctor said that you have a heart problem?
Yes No
2. Do you ever have any pains in your heart or chest?
    Yes No
3. Do you ever feel faint or have episodes of dizziness?
    Yes No
4. Have you ever been told that you have high blood pressure?
    Yes No
5. Is there a history of heart disease in your family?
    Yes No
6. Do you know your cholesterol level?
    Yes No
7. Do you have any bone, joint, or muscle problems that could be aggravated by exercise or activity?
    Yes No
8. Have you ever been diagnosed with asthma? List any and all medical conditions that could be aggravated by exercise? 
    Yes No
9. Have you ever been diagnosed with diabetes?
    Yes No
10. How many days per week are you involved in cardio/aerobic activity?

1 2 3 4 5 6 7


11. Check each activity below that you regularly incorporate into your exercise program.

Biking Indoor or Outdoor
Stair Climber
Aerobics Classes
Organized Sports
Interval Training

12. How long does each aerobic session usually last?

  0-18 min.
19-35 min.
36-60 min.
Over 60 Min.
13. How many days per week are you involved in weight resistance exercise?
  0 1 2 3 4 5 6 7
14. Which best describes your past exercise and activity history.
  No Activity
Somewhat active
Very Active most days
Active and exercised my entire life

15. Which best describes you overall nutritional habits?

  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.
16. A dim light or slight noise will wake me at night.
17. I seem to be gaining weight around my stomach.
  A lot
Not much
No weight gain
Losing weight currently
18. I push for doing things my way.
19. When completing a task, I can say, that I am satisfied with what I did.
  Almost never
20. At the end of my workday, I am very tired.
  A lot
21. Are you interested in Personal Training? Yes No
* 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.
  I Agree
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Additional Comments or Questions

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