JUMPING JACS
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>
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Cardiovascular Conditions and Disorders
>
Atrial Fibrillation
chronic heart failure
Myocardial Infarction (MI)
Peripheral Arterial Disease (PAD)
Muscle and Skeletal Conditions
>
Lower Back Pain (LBP)
Osteoarthritis
Osteoporosis
Metabolic Conditions
>
Obesity
high blood pressure (hypertension)
Diabetes Mellitus (Type 2)
Free Content (registration is free)
>
Workouts
>
Body Weight and Bands
TRX/Suspension Workouts
Goals
>
SMART Goals
FITT
Nutrition
>
Nutrition
>
Nutritional Resources
Flexibility
>
SMR & Foam Rolling
Dynamic Stretching
Static Stretching
Preparation
>
To Ice or to Heat?
Training When Sick
Hot Weather Trng Protocol
hydration
Feet
Client Resource Library
>
Topic Videos
*all information is confidential and follows our
privacy policy
Health Screening questionnaire (HSQ)
*
Indicates required field
Name
*
First
Last
age
*
Email
*
height
*
weight
*
Occupation
*
What brings you in today? What would accomplishing this goal mean for you?
*
SECTION 2: CURRENT AND PLANNED PHYSICAL ACTIVITY LEVEL
How active have you been over the last 3 months? (inactive if not active at least 30min, 3 days per week)
*
How often are you planning to exercise?
*
Are there any exercises you especially dislike or have a problem with?
*
What have been your obstacles to exercising in the past?
*
What obstacles have you had to proper nutrition? (could be education, access, time, etc)
*
Are there any foods you especially dislike or have a problem with?
*
What professional assistance have you sought to assist you in these challenges?
*
SECTION 3: MEDICAL CONDITIONS
(check all that apply)
Have you had or do you currently have:
*
A heart Condition or ever seen the doctor about your heart, or pulmonary (stroke) system?
High blood pressure
High cholesterol
Diabetes
None of the above
continued...
*
Renal disease
Asthma/COPD/ other respiratory disease
Arthritis
Currently pregnant
None of the above
Any medical/health condition not listed?
*
Are your medical conditions controlled with medication? If no please explain here:
*
Have you ever attended or been referred to physical therapy? If so please add detail here:
*
Has your doctor ever given you any limitations or parameters on your physical activity? Note condition details and limitations here:
*
SECTION 4: Current Condition
Do you currently experience:
*
Chest discomfort with exertion
Unreasonable breathlessness
Dizziness, fainting, or blackouts
None of the above
Continued...
*
Ankle swelling
Unpleasant awareness of a forceful, rapid, or irregular heart rate
Burning or cramping sensations in your lower legs when walking a short distance
None of the above
If you answered yes to any of the above please add detail here:
*
SECTION 5:
(physical)
Do you have any aches/pains, or are there any movements that cause you pain?
*
Have you ever been pregnant or had diastasis recti?
*
What past surgeries have you had? Please details
*
Have you ever had a joint replacement?
*
Section 6:
(Medications)
Are you CURRENTLY taking any medications?
*
No
Yes
If yes, please list the medications, the medical condition and how often you take them i.e. Daily (D), or as needed (PRN)
*
Are you taking all the medications you have been prescribed?
*
No
Yes
N/A
If there are medications you are prescribed but not taking please list the medication and why you're choosing not to take it:
*
Section 7: For Virtual and Fitness Support clients only
Do want workouts for at home, in a hotel, in a gym or a combination?
*
List all equipment you have here, if you will be doing all body weight, please say body weight only. If you'll be in a small (i.e. apartment gym) gym please list equipment. If in a commercial gym just say gym.
*
Section 8: Informed Consent Form For Jumping JACs
I the undersigned, give my consent to participate in the physical fitness evaluation program conducted by Jumping JACs.
BENEFITS:
Participation in a regular program of physical activity has been shown to produce positive changes in a number of organ systems. These changes include increased work capacity, improved cardiovascular efficiency, and increased muscular strength, flexibility, power and endurance.
RISKS:
I recognize that exercise carries some risk to the musculoskeletal system (sprains, strains) and the cardio-respiratory system (dizziness, discomfort in breathing, heart attack).
Declaration:
I hereby certify that I know of no medical problem (except those noted above) that would increase my risk of illness and injury as a result of participation in a regular exercise program.
Testing and Evaluation Results:
I understand that I may undergo initial testing to determine my current physical fitness status. The testing may consist of completing this health inventory, taking a step test or bicycle ergometer test for cardiovascular fitness, and being tested for muscular fitness and body composition. I further understand that such screening is intended to provide Jumping JACs with essential information used in the development of individual fitness programs. I understand that my individual results will be made available only to me. I also understand that the testing is not intended to replace any other medical test or the services of my physician. I will be provided a copy of all test results. I may share the results with whomever I please, including my personal physician. By signing this consent form I understand that I am personally responsible for my actions during my tenure at/with Jumping JACs, and that I waive the responsibility of Jumping JACs if I should incur any injury as a result of my negligence.
Typing your name is the equivalen to a signature for consent, please type you full name if you consent.
*
Submit
ABOUT
About Jeremy
Contact
Testimonials
In The Media
Privacy Policy
Services
In-Person Private Training
Private Virtual Training
Fitness Support
content
Blog
Videos
Exercise-U
Guidelines
>
Exercise for General Health
Exercise for Health in Children and Adolescents
Pregnancy and Postpartum
Cardiovascular Conditions and Disorders
>
Atrial Fibrillation
chronic heart failure
Myocardial Infarction (MI)
Peripheral Arterial Disease (PAD)
Muscle and Skeletal Conditions
>
Lower Back Pain (LBP)
Osteoarthritis
Osteoporosis
Metabolic Conditions
>
Obesity
high blood pressure (hypertension)
Diabetes Mellitus (Type 2)
Free Content (registration is free)
>
Workouts
>
Body Weight and Bands
TRX/Suspension Workouts
Goals
>
SMART Goals
FITT
Nutrition
>
Nutrition
>
Nutritional Resources
Flexibility
>
SMR & Foam Rolling
Dynamic Stretching
Static Stretching
Preparation
>
To Ice or to Heat?
Training When Sick
Hot Weather Trng Protocol
hydration
Feet
Client Resource Library
>
Topic Videos