Assessment Form for Jen
First Name: Jen
Height: 5 feet, 5 inches
Weight: 150 pounds
|X||Has your doctor ever said you have heart trouble?|
|X||Do you frequently have pains in your heart and chest?|
|X||Do you often feel faint or have spells of severe dizziness?|
|X||Has a doctor ever said your blood pressure was too high?|
|X||Are you over age 65 and unaccustomed to vigorous exercise?|
|X||Are you pregnant?|
|Do you have any of the following conditions?|
|X||Are you taking any medications that could affect your capabilities and levels of exercise?|
|X||Is there another health reason not mentioned here why you should not follow an exercise program?|
2. What daily medications and vitamins do you take? Multiple vitamin, Folic acid, Psyllium husk caps and sometimes Valerian root at night
3. Do any blood relatives have diabetes, heart trouble or high blood pressure?No
4. If yes, please specify:
5. Please describe your typical daily food & beverage intake including snacks and amounts:
|Typical Breakfast||Typical Lunch||Typical Dinner|
|Bowl of raisin bran or shredded wheat with soy milk and ½ banana
½ cup coffee w/fat-free creamer
|Sandwich (usually turkey) or sometimes a salad (chicken Caesar w/lite dressing)||Salad w/soy nuts and lite Ranch dressing (sometimes also anchovies)
Piece of grilled chicken or fish (occasionally steak)
Sometimes rice and fat-free beans
|Typical Snack||Typical Snack||Typical Snack|
Sometimes a fruit smoothie (raspberries, ice, nonfat yogurt, cranberry juice and sometimes ½ banana)
|Glass of chocolate soy milk or cranberry juice
Low-fat Triscuit crackers
6. How many meals do you eat out per week typically? zero to one
7. What type of restaurants do you frequent? “healthy” Mexican
8. Do you drink alcohol? No If yes, how often? n/a
9. List any food allergies: lactose-intolerant
10. List foods you crave: fruit, black licorice, lemonade/cranberry juice and sometimes a Coke
11. Describe your mood and/or situation when you snack: I typically snack so I don’t bonk when exercise (either an hour or so before or immediately after). I also snack prior to waiting for dinner or when I haven’t brought lunch to work and don’t have time to get it.
12. What do you attribute your weight problems to? I’m unsure, actually. I eat healthfully and get exercise. I know everyone says this, but I do think I have slow metabolism.
13. In the past, what ways have you tried to lose weight? Exercise and diet
14. Have you been exercising regularly (minimum two times per week) for at least the past eight weeks? Yes
15. If yes, briefly describe your routine: I just completed my 2nd marathon June 4, so my routine has been strictly running for the past four or five months.
16. How many days per week can you realistically devote to exercise? 6-7
17. How many minutes can you realistically devote per exercise session? 60 minutes
18. What physical activities are you interested in doing and have easy access to? Strength training, hiking, golf, cycling, elliptical trainer, walking, running. I’ve done a little lap swimming in the past and am considering this again. I have access to a pool and gym.
19. What is your resting heart rate? 60 beats per minute
(To determine resting heart rate, get into a sitting position. Place two fingers on your wrist and feel for your pulse. Count the number of pulses in 30 seconds.)
20. Provide the following measurements: Waist 32 inches; Hip 42 inches
21. What is your waist-to-hip ratio? .76
22. If female, what is your dress size? 10 to 12
23 . If male, what is your pants size at waist?
24. What is your primary reason(s) for participating in an exercise and nutrition program? Get a more toned torso, lose 10-15 pounds, loosely fit into a 10 always (rather than a snug 10 at present), segue into a fit pregnancy.
Welcome to the Four Get Fit program. You’ve outlined your reasons for joining the program and I think your goals are not only worthwhile but also attainable – especially given your history of physical activity and your access to a variety of exercise forms.
What I’ve done below is design an exercise plan that suits your needs and interests. I hope this plan, along with my guidance and direction, will help you meet your goals in a timely fashion. Obviously most of the work falls on your shoulders — you have to follow the plan in order to reap the rewards. I’ll be standing on the sidelines cheering you on over the course of the program!
There are three main types of exercise that you’ll need to participate in so that you can reach and maintain a healthy, well-balanced fitness level. These types are cardiovascular, strengthening/toning and flexibility.
Read on, Jennifer, for your exercise prescription. I’ll look forward to hearing from you next week when you send me your log and journal. Please be sure to detail your activity and don’t hesitate to ask any questions you have pertaining to fitness.