Medical and Health History Form

Katie McCarthy

Spring Semester

Exercise Physiology

Dr.Biren

(n.d.). Retrieved February 8, 2015, from

Medical and Health History Form

NameKatie McCarthy

Age 30

M or Ffemale

Height 5’7”

Weight 136 lbs.

Do you take any medications? If yes, what? Y or N No

Do you have any allergies? If yes, what? No

Female- Are you pregnant?No

Family/Personal History-Answer Yes or Noand whom to the following:

Diabetes Y or N -whom? Yes=Mom

High Cholesterol Y or N-whom? No

High Blood Pressure Y or N-whom? No

Heart disease Y or N-whom? No

Sudden death in the immediate family related to medical?-whom?-From what? No

Do you have any restrictions to exercise? If yes, what? No

Do you ever feel dizziness or nausea during exercise? Y or NNo

Do you have any injuries? If yes, what? No

Have you had any surgery?If yes, what? No

Have you ever had any pain or discomfort in your chest area? Y or NNo

Lifestyle Questionnaire

Do you take any vitamins and/or supplements? If yes, what? Yes=Pre-natal vitamins

Do you drink alcohol? Y or N- How often? Yes, two times per week. Red wine

Do you smoke currently or have quit within the past 6 months? Y or N- How often? No

How many hours of sleep do you get? 8 hours

How often do you exercise-within the last 3 months? Three times per week

What does your diet consist of?

Fruits Y or N-How much per week? Yes 4 times per week

Vegetables Y or N- How much per week?Yes 6 to 7 times per week

Fatty Foods Y or N- How much per week? Yes 1 to two times per week

Red meat Y or N- How much per week? Yes 0 to 1 times per week

High in fiber foods Y or NYes

High in Protein Y or NYes

High in sugar Y or NYes 1 to 2 times per week

What is your goal? I would like to increase my workout days from 3 days to at least 4 days a week.

What results would you like achieve? I want to gain more upper body strength and build my core strength up. I also want to tone my overall body, but mostly my triceps and biceps.

Do you have any personal barriers to achieving your goals? I attend school Monday, Tuesday, Wednesday, and Thursday. I bar-tend Tuesdays (after school), Fridays and Sundays. I cut hair on Thursdays after school. I am always too exhausted to work out anymore than I already do.

Emergency Contact:

Name James McCarthy Phone # 1-609-774-4245 RelationshipHusband

Insurance Information:Aetna

RiskStratification Scoring Positive Risk Factors Defining Criteria Points

Age Men ≥ 45 years, Women ≥ 55 years +1

Family History Myocardial infarction, coronary revascularization, or sudden death before 55 years of age in father of other 1st degree male relative or before 65 years of age in mother or other 1st degree female relative +1

Cigarette Smoking Current cigarette smoker or those who quit within the previous six months, or exposure to environmental tobacco smoke (i.e., secondhand smoke) +1

Sedentary Lifestyle Not participating in at least 30 minutes of moderate-intensity physical activity on at least three days/week for at least three months +1

Obesity Body mass index ≥30 kg/m2 or waist girth >102 cm (40 inches) for men >88 cm (35 inches) for men +1

Dyslipidemia Low-density lipoprotein (LDL) cholesterol ≥ 130mg/dL(3.37 mmol/L) or high-density lipoprotein (HDL) cholesterol 200 mg/dL (5.18mmol/L) +1

PrediabetesFasting plasma glucose ≥100 mg/dL (5.50 mmmol/L) +1

High HDL Cholesterol ≥60 mg/dL (1.55 mmol/L) -1

I am categorized at a “low risk” level according to the ACSM Risk Stratification Levels. It is not necessary to get a physician clearance prior to exercise. The stipulations to be at “Low Risk” are as follows: A person is must be asymptomatic with no more than 1 risk factor. I can participate in moderate exercise (40-60% of VO2max) or vigorous exercise (>60% of VO2max).

Assessments / Test / Student’s Score / Norms or Standards / Needs Improvement or Maintain
Cardiovascular / Pacer / 80 laps / 35.4-38.5 / Maintain
Muscular Endurance / Push-ups
Curl-ups / 7 push-ups
43 Curl-ups / 7
18 / Maintain
Maintain
Muscular Strength / Max Bench Press / 70 lbs. 1 rep.
70lbs./136=.51 / 0.48-0.53=Fair
Ages 30-39 / Needs Improvement
Flexibility / Shoulder Stretch
Trunk Extensor
Back Savor / Left: Y Right: Y
12 inches
Left: 6 ½ in.
Right: 7 in. / Shoulder Stretch=Touching fingertips together behind back on both right and left sides.
Trunk Extensor= 9-12 in.
Back Savor=12 in. / Shoulder Stretch=Maintain
Trunk Extensor=Maintain
Back Savor =Needs Improvement
Body Composition / BMI Imperial Formula / 21.29 / BMI < 18.5= underweight
BMI 18.5-24.9=normal
BMI 25-29.9=overweight
BMI >30=obese / Maintain
Speed / 40 Meter Dash / 7 seconds / Average rating / Maintain
Agility / Shuttle Run / 11 seconds / Average rating / Maintain
Power / Vertical Jump / Standing measurement=85 in.
Jumping measurement=102 in. / 17 in.
Above Average= 16-20 in. / Maintain
Balance / Stork Balance Test / Right foot =14seconds
Left foot
=13 seconds / Excellent= >50sec.
Good=40-50sec.
Average=25-39sec.
Fair =10-24 sec.
Poor= <10 sec. / Needs Improvement

I am considered to be at the low risk level for working out. I am in the normal range for BMI. I need to maintain my physical fitness for many of my fitness assessments. One of my concerns is that I did score very low in the flexibility back savor. My core strength concerns me as well. It is not that strong which is why I think I did not score very well in my balance test. My biggest concern is my lack of upper body strength. Another concern of mine is cravings for sugary foods and fatty foods. I would like to eat less fatty foods and foods high in sugar. I eat healthy foods majority of the time, but I still enjoy foods that are not healthy as well. I work out three days a week, but I would to increase my workout to four times a week. I plan on increasing my workout days by exercising right after school Monday through Thursday, because I won’t have any energy to do so after work. I have problems staying motivated to eat healthy all the time and work out in the winter. It is so cold and it makes me want to just lounge around. I still do it, but I dislike working out in the winter; I don’t enjoy it. I have great motivation when the weather is nice. I love running outside, bike riding, playing softball, playing field hockey and swimming. I feel like there are many more activities to engage in during the spring, fall and summer. I just started playing indoor field hockey, which I will count as my enjoyable exercise. This will help keep me motivated to continue to work out, so that I continue to stay in shape to perform at my best on the field.

Strengths

 Cardio vascular endurance

 Trunk extensor

 Shoulder stretch

 Curl-ups

 Agility

 Speed

 Smoke free

 Asymptomatic

 No medical conditions

Weaknesses

 Lack in upper body strength

Lack of flexibility in Hamstrings

 My balance is not that great.

 I eat healthy, but still enjoy my sweets and fatty foods now and then.

 I like having a couple of glasses of wine 1-2 times per week.

 The cold winter makes my lazy.

Short term goal

 Increase my upper body strength

 Increase my core strength

 Increase my flexibility

 Tone my triceps and biceps.

Long term goal

 Find ways to stay motivated to work out in an enjoyable way during all seasons to stay healthy and fit.

Plan

My plan is to increase my workout days from three days a week to four days a week. I plan on working out after school, because I am always too exhausted to work out after work. I am going to do vigorous cardio for 20 minutes a day, three days a week. My exercises will include running, mountain climbers, burpees and superman/ banana P-90X exercise. This will help build my core and strength. I will count my two field hockey games that I play in on Saturdays as my enjoyable bonus exercise. To increase my muscular strength and endurance, I am going to work out at 60-70% 1RM, 3 sets of 12-15 reps. My exercises will include pushups, pull-ups, bench presses, bicep curls and chair dips for upper strength and toning. I will also do squats, walking lunges and leg presses to help with my lower body strength. To increase my flexibility, balance and strength, I will do “hatha” yoga and hamstring stretches. I also am taking a dance class at Rowan University that will help with my strength, endurance, flexibility and balance. I also like to include work out videos such as T-25 for when I am pressed for time. Those videos help motivate me as well, because sometimes I need a push from a trainer. I am going to work out with my husband, so that we can keep each other motivated.

Assessments / Test / Student’s Score / Norms or Standards / Needs Improvement or Maintain / Re-evaluation
Cardiovascular / Pacer / 80 laps / 35.4-38.5 / Maintain / 90 laps
Muscular Endurance / Push-ups
Curl-ups / 7 push-ups
43 Curl-ups / 7
18 / Maintain
Maintain / 15 push-ups
55 Curl-ups
Muscular Strength / Max Bench Press / 70 lbs. 1 rep.
70lbs./136=.51 / 0.48-0.53=Fair
Ages 30-39 / Needs Improvement / 95 lbs. 1 rep.
Flexibility / Shoulder Stretch
Trunk Extensor
Back Savor / Left: Y Right: Y
12 inches
Left: 6 ½ in.
Right: 7 in. / Shoulder Stretch=Touching fingertips together behind back on both right and left sides.
Trunk Extensor= 9-12 in.
Back Savor=12 in. / Shoulder Stretch=Maintain
Trunk Extensor=Maintain
Back Savor =Needs Improvement / Left: Y
Right: Y
12 inches
Left: 9 in.
Right: 9 in.
Body Composition / BMI Imperial Formula / 21.29 / BMI < 18.5= underweight
BMI 18.5-24.9=normal
BMI 25-29.9=overweight
BMI >30=obese / Maintain / 21.29
Speed / 40 Meter Dash / 7 seconds / Average rating / Maintain / 7 seconds
Agility / Shuttle Run / 11 seconds / Average rating / Maintain / 11 seconds
Power / Vertical Jump / Standing measurement=85 in.
Jumping measurement=102 in. / 17 in.
Above Average= 16-20 in. / Maintain / Standing measurement= 85 in.
Jumping measurement= 102 in.
Balance / Stork Balance Test / Right foot =14seconds
Left foot
=13 seconds / Excellent= >50sec.
Good=40-50sec.
Average=25-39sec.
Fair =10-24 sec.
Poor= <10 sec. / Needs Improvement / Right foot=21seconds
Left foot=18seconds

Overall, my re-assessment scores improved! My speed, agility, and power all remained the same. My balance improved, but it is not as good as I would like it to be. I plan on participating in more yoga to improve my balance. Doing daily stretches helped improve my results for the back savor. My upper body strength improved greatly! Pushups, burpees, triceps dips, and biceps curl helped with improvement. My goal was to improve my overall strength, but mainly my upper body strength. My long term goal was to find activities to participate in during all seasons to stay active, and I was successful. Participating in this project motivated me to work out during the cold winter, so thank you. It has always been a struggle for me to continue exercise during all seasons. I challenged myself to explore activities that I could participate in without letting the weather being a factor. I participated in indoor field hockey, indoor rock climbing, dance class, and indoor volley ball to stay active. I plan on continuing to explore new activities to participate in. Now that it is nice out; I have a variety of activities to choose from. My future goal is to continue staying active and finding new activities to explore. I also want to challenge myself to try cross fit exercise to increase my strength. My husband and I are going to join a cross fit gym. I’m always up for trying new things!

References

Your Prescription for Health Exercise is Medicine. (n.d.). Retrieved February 8, 2015,

From D

- ACSM Risk Stratification Q.pdf