Form FMPF 13-8320-0043NHE-CATF 96033350112

ORC [Other Relevant Condition(s)]:
1) Post-traumatic Arthritis in right knee. (Doctored cleared)
2) Acute low back discomfort. (Doctored cleared)


Notes: 
Health Questionnaire.

1) [No]   
2) [No]   
3) [Yes]   
4) [No]   
5) [No]   
6) [No]   
7) [No]   
8) [No]   
9) [No]   
10) [No]  
11) [No]  
12) [No] 
1) Ischemia.
2) Smoke.
3) Drink [beer, six pack on weekends].
4) Edema.
5) Known heart murmur.
6) Intermittent claudication.
7) Palpitations or tachycardia.
8) Shortness of breath at rest or with mild exertion.
9) Dizziness or syncope at rest or with mild exertion.
10) Unusual fatigue or shortness of breath with usual activities.
11) Orthopnea/paroxysmal nocturnal dyspnea at rest or w/mild exertion.
12) Pain or discomfort (or anginal equivalent) in the chest, neck, jaw, arms. 
NHE Fitness Management Profile Form (FMPF) Sample


Resting BP: 
132/85   
       
Resting HR:
70          

Height:
5 Ft 10 in     
     
Physical Limitations:
Restricted ROM in RT deltoid

Bioelectrical Impedance Reading:Sex: M
BF%:17        
Body Measurements: 
Chest: 46 inNeck: 17 in
Waist: 41 inHips: 40 in    
Ankle: 10/10 in (Right/Left)    
Upper Arm: 15/ 15.5 in (Right/Left)  
Thigh: 24.25/24in (Right/Left) 
Wrist: 8/8 in (Right/Left)
Calf: 16/16.25 in (Right/Left)   
Profile Name: 
Carter, Steven   

Profile Date: 
June/2019 

Weight: 
207 lbs    

Age: 
32     

Fitness Goal(s): 
1) Lose 15-20 pounds.
2) Increase biceps and triceps strength and size. 
3) Strengthen core.
4) Improve cardiovascular endurance.



Fitness Access/Schedule: 
Complete cardio/WT facility. 45-60 min, 3xWK.
Fitness Assessment (In relation to member's profile):
1) Program Type Preference: Normal, not too advanced.
2) Cardiovascular: Poor
3) Weight Training Experience: High school football
4) Muscular Endurance: Average
5) Cardiovascular Machine Favorite: Treadmill
6) Muscular Strength: Average
7) Exercise Terminology: Average
8) Flexibility: Poor
9) Core Development: Poor
Family History.

1) [No]   
2) [No]   
3) [No]   
4) [No]   
5) [No]   
6) [Yes]   
7) [No]   
8) [No]   
9) [Yes]   
10) [No]  

1) Heart attack or surgery prior to age 55.
2) Stroke prior to age 50.
3) Congenital heart disease or left ventricular hypertrophy.
4) Hypertension.
5) Leukemia or cancer prior to age 60.
6) High cholesterol.
7) Diabetes.
8) Asthma.
9) Osteoporosis.
10) Depression.
Medications.

1) [No]   Diuretics
2) [No]   Beta Blockers
3) [No]   Vasodilators 
4) [No]   Alpha Blockers
5) [No]   Calcium Channel Blockers
6) [No]   NSAIDS
7) [No]   Cholesterol
8) [No]   Diabetes.Insulin
9) [No]    Birth Control
10) [No]   Other Drug
Anatomical Concerns:


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