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Last Name

Age

Gender

Weight

Height

Occupation

Water Intake?

Sleeping Habits?

Current Workout Frequency

What Is Your Time Commitment?

Do you?:

smoke (and over the age of 35) drink excessively (more than 1-2/day) have poor sleeping habits (less than 8 hrs/night regularly)

Do you have diabetes?

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Do you have a history of high blood pressure?

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Do you have a family history of coronary disease prior to age 50?

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Have you ever had?:

a heart attack cardiac surgery extreme chest discomfort high blood pressure (over 140/90) heart murmurs ankle swelling any vascular disease unusual shortness of breath fainting spells asthma, emphysema, or bronchitis

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