Golf Fitness Profile

General Information

Name _____________________________ Age _______ Gender           M         F

Address ____________________________ City/State/Zip _________________

Email address _______________________ Phone ________________________

Date of Birth _____________ Height___________Weight_____________

How did you hear about Jill Martin Golf Fitness?

 ______________________________

Golf Information

You are a right/left handed golfer. What is your handicap? _________________

How many times per week do you play golf on average? ___________________

Who is your local golf pro? __________________________________________

What are you working on with your swing? _____________________________

_______________________________________________________________

Name two things you’d like to see change in your game or swing? ___________

________________________________________________________________

Main goals: treat an injury ____, prevent an injury ____, improve golf

performance ____, develop a golf fitness routine ____, other ________________

Fitness Information

How long have you been working out? _________________________________

Describe your usual work outs (frequency, time, equipment, exercises, etc.) ____

_________________________________________________________________

_________________________________________________________________

What exercise equipment do you have available to you? ___________________

_________________________________________________________________

_________________________________________________________________

What days do you prefer to work out? __________________________________

____ Mon, ____ Tues, ____ Wed, ____ Thurs, ____ Fri, ____ Sat, ____ Sun

Medical Information

Are you here for a specific injury or medical diagnosis? Y N ______________

Please check if you have any problems with your: ____ low back, ____ neck,

____ shoulder, ____ elbow, ____ wrist, ____ hip, ____ knee, ____ ankle

Please elaborate on other pertinent past injuries. ___________________________________________________________

Do you have a doctor’s permission to exercises? Y N

Do you have a family history of heart disease? Y N

Has your doctor ever told you that you have a heart condition? Y N

If so, please describe the condition. _____________________________________

Have you had chest pain while exercising or engaging in physical activity? Y N

Have you had dizziness or loss of consciousness while exercising or engaging in

physical activity? Y N

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