Alexis Foy | Personal Trainer

NASM Certified

Services & Programs

Performance Assessments
Flexibility Training
Cardiorespiratory Training
Core Training
Balance Training
Reactive Training
Speed, Agility & Quickness Training
Suspension Training (TRX)
Instructional Workshops
Physiological Assesments

Click Here For Rates

Telephone 910.263.6411

Address alexis@personaltrainercary.com

1000 Heathmoor Lane
Cary, NC 27513

Also Try:
Frank Lech, Personal Training in Cary

General Medical History

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?	Yes	No
Do you feel pain in your chest when you perform physical activity?	Yes	No
In the past month, have you had chest pain when you are not performing any physical activity?	Yes	No
Do you lose your balance because of dizziness or do you ever lose consciousness?	Yes	No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?	Yes	No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?	Yes	No
Do you know of any other reason why you should not engage in physical activity?	Yes	No

General Medical History (Continued)

Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?	Yes	No
Please explain.
Have you ever had any surgeries?	Yes	No
Please explain.
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes?	Yes	No
Please explain.
Are you currently taking any medication?	Yes	No
Please list your medications.

Occupation

What is your current occupation?
Does your occupation require extended periods of sitting?	Yes	No
Does your occupation require extended periods of repetitive movement?	Yes	No
Please explain.
Does your occupation require you to wear shoes with a heel (dress shoes)?	Yes	No
Does your occupation cause you anxiety (mental stress)?	Yes	No

Lifestyle

Do you partake in any recreational activities (golf, tennis, skiing, etc.)?	Yes	No
Please explain.
Do you have any hobbies (reading, gardening, working on cars, etc.)?	Yes	No
Please explain.

Contact Information

Name:
Email address:
Phone Number:

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