Please, fill this form

List of questions (anamnesis)

Full Name

Age:

Contact Phone:

Experience sports, what kind of?

Where will engage?

What kind of equipment you have and what you can buy (sports equipment)

If you want to train at home, tell us about the circumstances, whether there is a place at what time
I want to, and whether you will interfere with anyone else?

If in the Gym then I need to know there are some trainers machine

Wishes that you feel you need to fix it, and what you think you have flaws?

Contraindications to compile the program

Have you ever suffered:

From heart problems?
yesno

From back problems?
yesno

From asthma?
yesno

From gallstones or kidney stones?
yesno

From diabetes saharennym?
yesno

From any source of bleeding
(nose, stomach, hemorrhoids, etc.)?
yesno

You are raising or lowering blood pressure?
yesno

There are chest pain?
yesno

There are heart attacks or interruptions in the heart?
yesno

Do you feel shortness of breath and rapid walking or climbing stairs?
yesno

There you have swelling in the legs in the evening?
yesno

Oncologist?
yesno

Psychiatrist?
yesno

Do you have thyroid disease?
yesno

List than rooting for the past year, all possible infections, viral infections, surgery, injuries and more
yesno

Have you ever had a head injury with loss of consciousness?
yesno

Do you suffer from chronic kidney disease?
yesno

Radiculitis?
yesno

Varicose veins?
yesno

There you have fainting?
yesno

Dizziness?
yesno

Have you had in the last year childbirth?
yesno

Whether there were complications related to childbirth?
yesno

Do you come climax?
yesno

Do you suffer from gynecological diseases?
yesno

Whether there are failures in menstruation?
yesno

Your work is mostly sedentary?
yesno

Smoking Do?
yesno

Whether there were your parents such diseases (myocardial infarction, hypertension, diabetes mellitus)
yesno

Do you suffer from insomnia?
yesno

Did you ever have an increased heart rate, on the red faces when communicating with strangers and unusual situation?
yesno

Whether there is that your mood changes dramatically throughout the day?
yesno

There you have outbursts of anger?
yesno

Do you have concerns about the state of health?
yesno

Do you feel dissatisfaction with themselves, their actions and deeds?
yesno

Resting blood pressure (digits)

Heart rate at rest (figures)

Nutrition

I need to you within seven days of the commencement of the work carried food diary.
Every day, write down everything that you eat, detail, indicating the weight and time
(example: if a sandwich, then some bread, sausage and fat content of butter and,
accordingly, at least approximate weight, if coffee is how many spoons of coffee and
how much sugar and so on) more fully and accurately you describe your diet for a week,
the better I can help you.

According to the regime:

Please describe your work (weekday) and not working (output) day, fully, in detail, by the hour.
When you get up, eat, work, what do you do during the day.
What is your job (only mental labor, physical, and so on).

Still it is necessary to write a separate report

Date of commencement of work age:

Weight:

Height:

Neck:

Chest:

Biceps:

Waist:

Buttocks:

Left Thigh:

Right Thigh:

Calfs: