Registration

Thank you for showing interest in CF Fitness. Please complete the initial registration form below so we can learn a little more about you.

Last Name *
First Name *
E-Mail Address *
Address *
City *
State *
Zip *
Phone Number *
Age
Height
Weight
Current Activity/Job
Short Term Goals
Long-Term Goals
Current Medical Problems (Heart, lungs, diabetes, etc.)
Physician-Prescribed Medications
Allergies to medicine, trees, grass, or foods
Number of meals per day (chicken, fish, beef, junk food, etc.)
Number of glasses of water per day (approximately)
Amount of fruit consumed in a day (approximately)
Daily Caloric Intake (If Known)
How many days a week can you contribute to exercise?
What type of facility will you be working out at? (Be as specific as possible, please)

Please check the following boxes if you've had/have (optional):

A Heart Attack? Yes
Heart Surgery Yes
Cardiac Catheterization Yes
Coronary Angioplasty (PTCA) Yes
Pacemaker/Implantable Cardiac Defibrillator/Rhythm Disturbance Yes
Heart Valve Disease Yes
Heart Transplantation Yes
Congenital Heart Disease Yes
Chest discomfort with exertion (exercise)? Yes
Unreasonable Breathlessness Yes
Dizziness, fainting, blackouts? Yes
Musculoskeletal Problems? Yes
Do you have concerns about the safety of exercise? Yes
Are you pregnant? Yes
Do you take heart medication? Yes
You are a man older than 45 years Yes
You are a woman older than 55 years or you have had a hysterectomy or you are postmenopausal Yes
You smoke Yes
Your blood pressure is greater than 140/90 Yes
You don't know your blood pressure Yes
You take blood pressure medication Yes
Your blood cholesterol level is >240mg/dL Yes
You have a close blood relative who had a heart attack before age 55 (father or brother) or age 65 (mother or sister) Yes
You are diabetic or take medicine to control your blood sugar Yes
You are physically inactive (i.e., you get less than 30 minutes of physical activity on at least 3 days per week) Yes

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