Posture Alignment Training Questionnaire

Please answer the following questions and click "submit" when finished. Upon submission, your questionnaire will be sent to the Fitness Coordinator and a trainer will contact you within 2-3 business days.

Please select the Posture Alignment Trainer you want to work with

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Contact name*

Please let us know your name.

Address*

Please let us know your name.

Phone number*

Please enter your phone number with area code.

Height*

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Weight*

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Your age*

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Email address*

Please let us know your email address.

Your occupation*

Please let us know your message.

Your Employer*

Please let us know your message.

Emergency Contact*

Please let us know your message.

Emergency Contact Phone

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Physician's Name

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Clinic Address

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Clinic Fax Number

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How did you hear about Posture Alignment Training at the ECC? Please check all that apply.

In-house materialsWeb siteEmailReferred by someoneInformation at workplaceLocal newspaperEagan TVReceived information in the mail Invalid Input

Other

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Why did you choose to train at the Eagan Community Center instead of another organization?

LocationTrainersCustomer ServiceWord of MouthPrice Invalid Input

Other

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Have you ever worked with a Posture Alignment Trainer in the past

YesNo Invalid Input

If yes, please comment on that experience:

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Medical Health Status Questionnaire - On this portion of the form, a number of questions regarding your physical health are to be answered. Please answer every question as accurately as possible so that a correct assessment can be made. Please place a tick in the space to the left of the question to answer "Yes." Leave blank if your answer is "No." Please ask if you have any questions. Your responses will be treated in a confidential manner.

Today's Date*

You must select a date

Medical Screening - ACSM Medical Status Questionnaire

Do you have any personal history of heart disease (coronary or atherosclerotic disease)?Any personal history of diabetes or other metabolic disease (thyroid,renal,liver)?Any history of pulmonary disease, asthma, interstitial lung disease or cystic fibrosis?Have you experienced pain or discomfort in your chest apparently due to blood flow deficiency?Any unaccustomed shortness of breath (perhaps during light exercise)?Have you had any problems with dizziness or fainting?Do you have difficulty breathing while standing or sudden breathing problems at night?Have you experienced a rapid throbbing or fluttering of the heart?Do you suffer from ankle edema (swelling of the ankles)?Have you experienced severe pain in leg muscles during walking?Do you have a known heart murmur?Has your serum cholesterol been measured at greater than 200 mg/dl?Are you a cigarette smoker?Has your HDL (the "good" cholesterol) been measured at greater than 60 mg/dl?Would you characterize your lifestyle as "sedentary"?Have you had a high fasting blood glucose level on 2 or more occasions (>=110mg/dl)?Are you 20% or more overweight or have you been told your “BMI” was greater than 30?Have you been assessed as hypertensive on at least 2 occasions (systolic > 140 or diastolic > 90mmHg)?Do you have any family history of cardiac or pulmonary disease prior to age 55? Invalid Input

Are you currently being treated for high or low blood pressure?

YesNo Invalid Input

If you know your average blood pressure, please enter ____ / ____

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Medical History - Please Check All That Apply.

Abnormal Chest X-RayAbnormal EKGGastrointestinal IssuesFibromyalgiaPlantar FasciitisTendonitisAnemiaRheumatic FeverLimited Range of MotionJoint ReplacementTMJ

SciaticaScoliosisHip DysplasiaArthritisBursitisEpilepsy or SeizuresVisual ProblemsBifocalsBalance Problems or disturbancesInner Ear Infections/DamageChronic Headaches or migraines

Persistent FatigueStomach ProblemsEmphysemaKnee ProblemsHerniaAsthmaBack ProblemsAre You PregnantRespiratory IssuesShoulder ProblemsBronchitis

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Any Surgery

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Other Lung Problems

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Are you currently pregnant?

YesNo Invalid Input

Childbirth:

NaturalC-Section Invalid Input

Family History - Have your mother, father, or siblings suffered from (please select all that apply):

Heart attack or surgery prior to age 55.High cholesterolStroke prior to age 50.DiabetesCongenital heart disease or left ventricular hypertrophy.

ObesityHypertensionAsthmaLeukemia or cancer prior to age 60Osteoporosis

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Medications Please Select Any Medications You Are Currently Using

DiureticsBeta BlockersVasodilatorsAlpha BlockersCalcium Channel Blockers

Other CardiovascularNSAIDS/Anti-inflammatories (Motrin, Advil)Cholesterol controlDiabetes/Insulin

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Other Drugs - Please list the specific medications that you currently take:

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Are you a cigarette smoker?

YesNo Invalid Input

If yes, how many per day?

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Were you previously a cigarette smoker?

YesNo Invalid Input

If yes, when did you quit?

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If yes to either above, how many years have you smoked or did you smoke before quitting?

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What do you/did you smoke?

Cigarettes Cigars Pipe Invalid Input

Please Rate Your Daily Stress Levels (select one):

LowModerateHigh but I enjoy the challengeHigh: sometimes difficult to handleHigh: often difficult to handle Invalid Input

Do you drink alcoholic beverages? How many units of alcohol do you consume each week? Units Chart: 1/2 pint of beer = 1 1 glass of wine = 1 1 pub measure of spirits (gin, vodka, etc.) =1 1 can of beer = 1.5 1 bottle of strong lager = 2.5 1 can of strong lager = 4 1 bottle of wine = 7 1 litre bottle of wine = 10 1 bottle of fortified wine (port, sherry, etc.) = 14 1 bottle of spirits = 30

How many units of alcohol do you consume each week (based on chart)?

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Dietary Habits. Please Select All That Apply.

I seldom consume red or high-fat meatsI pursue a low-fat dietMy diet includes many high-fiber foods

I eat at least 5 servings of fruits/vegetables per dayI almost always eat a full, healthy breakfastI rarely eat high-sugar or high-fat desserts

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Please Indicate Any Other Medical Conditions or Activity Restrictions That You May Have. It is important that this information be as accurate and complete as possible.

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Is any of this information critical to understanding your readiness for exercise? Are there any other restrictions on activity that we should know about?

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Personal Fitness & Lifestyle Goals - In striving to achieve a higher state of wellness or fitness, a set of clearly articulated goals is essential. These goals will help to guide your lifestyle choices such as when and what to eat, how often and how intensely to exercise, and how to overcome the challenges and barriers you will surely encounter. Please Indicate Your Personal Health and Fitness Goals:

Aerobic Fitness Feel Better Flexibility General FitnessImprove Diet Injury Rehab Look Better Lose Weight

Lower Cholesterol Muscular Size Muscular Strength Reduce Back PainReduce Stress Sports Specific Stop Smoking

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Please tell us more about your exercise patterns and goals:

Exercise History:

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Exercise Needs:

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Please list 3 specific goals you would like to work toward:

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Activity Preferences:

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Barries to Success:

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Motivation Level:

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Confidence Level:

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Evidence of Success:

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Please use the space below to record 3 concrete commitments that you are willing to make to your own health goals. These should be challenging but also realistic and attainable commitments.

Concrete Commitments:

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How many times per week are you active enough to break a sweat?

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When you exercise, how long are you active?

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On a scale of 1 to 10, how intense is your typical activity?

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How many years have you exercised?

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Please check all of your activity preferences or interests:

Aerobics ClassGroup ActivitiesOutdoor CyclingStep AerobicsWalkingFree Weights

Martial ArtsRunningSwimmingGolfTennisOther

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Please check ALL times you could be available to train:

Monday:

MorningAfternoonEvening Invalid Input

Tuesday:

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Wednesday:

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Thursday:

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Friday:

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Saturday:

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Sunday:

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What is your primary reason for trying Posture Alignment Training?

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Do you have any concerns/questions in participating in PAT? Please discuss below, if so.

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List 3 things you would like to be able to do after PAT that you cannot do now? (i.e. run, golf, pick up grandchild etc.)

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What care are you currently under, if any?

AcupuncturistChiropractorMassage TherapistNutritionist

Physical TherapistPhysicianOther

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Do you have a specific diagnosis from your physician?

YesNo Invalid Input

If so, please describe.

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Do you have recommendations/restrictions from your physician?

YesNo Invalid Input

Do you currently wear orthotics?

YesNo Invalid Input

What are your current day to day activities?

BendingDriving/TravelingExtensive phone timeLiftingFine motor workProlonged standingProlonged sittingSitting at a computerWalkingOther Invalid Input

Do you have trouble sleeping due to pain/discomfort?

YesNo Invalid Input

On average, how many hours of sleep do you get each night?

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Do you have any other body pain or limitations related to issues such as childhood accidents, injuries or surgeries? Please describe.

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Please describe primary problems

Getting betterGetting worseStaying the same Invalid Input

What makes you feel better?

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What makes you feel worse?

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Current Symptoms: Please review the following questions regarding Location, Severity, Onset and Duration to your pain or body limitations:

Describe where it hurts

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Is it local or generalized?

LocalGeneralized Invalid Input

Does the pain change locations?

YesNo Invalid Input

What have you been told about your condition?

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Please rate your pain on a scale of 1-10

0 No pain1-3 Mild4-6 Moderate7-9 Severe10-Disabling (worst pain ever experienced) Invalid Input

When do you feel the pain come on?

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Is the pain constant or does it occur at a specific time of day?

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Is the pain related to any certain activity you do in your day? For example: bending over, sitting, walking, exercising

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How long does your symptom last?

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When the pain comes on, what do you do about it?

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What type of learner are you?

Auditory - Learn by hearingVisual - Learn by seeingKinesthetic - Learn by feeling or touching Invalid Input

I wish to participate in the exercise and training program offered by the Eagan Community Center (ECC). I understand there are inherent risks in participating in a program of strenuous exercise. Consequently, I have been examined by a physician of my choice and have obtained his/her written approval for my participation in a fitness program within sixty (60) days of the date set forth below. No change has occurred in my physical condition since the date such approval was given which might affect my ability to participate in the fitness program. I agree that the ECC shall not be liable or responsible for any injuries to me resulting from my participation in the fitness program (whether at home, outdoors, or at a corporate , commercial, residential or other fitness facility) and I expressly release and discharge the City of Eagan/ECC, employees, agents and/or assigns, from all claims, actions, judgments and the like which I or my heirs, executors, administrators or assigns may have or claim to have as a result of any injury or other damage which may occur in connection with my participation in the fitness program, excepting only an injury caused by the gross negligence or intentional act of such person or persons. This Release shall be binding upon my heirs, executors, administrators and assigns.