Part 1: General Information

Year of Birth:

Gender

Race

My Heart Fitness collects your race for a variety of reasons including program demographics, and to determine increased risk for cardiovascular disease

Part 2: Anthropometric Measurements

Imperial		Metric
Height:	in.	Height:	cm.
Weight:	lbs.	Weight:	kg.
Waist:	in. 🛈	Waist:	cm. 🛈

Part 3: Literacy

	yes	no
Are you comfortable reading English?	yes	no
Are you comfortable writing English?	yes	no
Are you comfortable comprehending English?	yes	no

What language are you most comfortable using/understanding?

Part 5: Cardiac Health History

Have you ever been diagnosed with any of the following heart conditions? (Select all that apply) 🛈

Part 5: Cardiac Health History

Have you ever been diagnosed with any of the following heart conditions? (Select all that apply) 🛈

Part 6: Risk Factors

	yes	no
Has any member of your family had a heart attack, stent, or bypass surgery at an early age? (men <55yo, women <65yo)	yes	no

What is your current smoking status?

	yes	no
Have you been diagnosed with Diabetes?	yes	no
Have you been diagnosed with high cholesterol?	yes	no
Have you been diagnosed with high blood pressure?	yes	no

Part 7: Medications

Please list your medications below. Include the medication name, dosage, and how many times per day you take it.

	Name	Dosage	Times per day
1	Name	Dosage	Times per day
2	Name	Dosage	Times per day
3	Name	Dosage	Times per day
4	Name	Dosage	Times per day
5	Name	Dosage	Times per day
6	Name	Dosage	Times per day
7	Name	Dosage	Times per day
8	Name	Dosage	Times per day
9	Name	Dosage	Times per day
10	Name	Dosage	Times per day

Part 8: Mental Health

How would you rate your overall mental health?

Mental health can be defined as emotional, psychological, and social well-being and can affect the way we think, act, or feel (Center of Disease Control and Prevention, 2021).

	Not at all	Several days	More than half of the days	Nearly every day
Little interest or pleasure in doing things	Not at all	Several days	More than half of the days	Nearly every day
Feeling down, depressed, or hopeless	Not at all	Several days	More than half of the days	Nearly every day
Trouble falling or staying asleep or sleeping too much	Not at all	Several days	More than half of the days	Nearly every day
Feeling tired or having little energy	Not at all	Several days	More than half of the days	Nearly every day
Poor appetite or overeating	Not at all	Several days	More than half of the days	Nearly every day
Feeling bad about yourself - or that you are a failure or have left yourself or your family down	Not at all	Several days	More than half of the days	Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching TV	Not at all	Several days	More than half of the days	Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual	Not at all	Several days	More than half of the days	Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way	Not at all	Several days	More than half of the days	Nearly every day

Part 9: Exercise

	yes	no
Do you currently exercise?	yes	no

Part 9: Exercise

Do you experience any of the following symptoms with exercise? (Select all that apply)

Part 9: Exercise

What are your current barriers to exercise? (Select all that apply)

Lack of time

Lack of experience/skill

Lack of funds

Lack of transportation

Not motivated

Intermittent weather

Musculoskeletal discomfort

None of the above None of the above

Part 10: Nutrition

Imagine your typical food plate. How closely do you feel it aligns with Canada’s Food Guide Snapshot (have plenty of vegetables and fruits, eat protein foods, choose whole grains foods, make water your drink of choice)?

https://food-guide.canada.ca/en/food-guide-snapshot/

1510

1-3: Does not include these items

4-6: Includes some of these items

7-10: Includes most/all of these items

Thanks for your information!

Your information has been saved! we will contact you shortly!

Arthritis	Irritable Bowel Syndrome
Asthma	Kidney Disease
Cancer	Mood Disorder
COPD	Osteoporosis
Dementia	Peripheral Vascular Disease
Diabetes	Sleep Apnea
Epilepsy	Cerebrovascular Disease
GERD	Gout
Heart Disease	Not Applicable
Other Other

Part 1: General Information

Part 2: Anthropometric Measurements

Part 3: Literacy

Part 4: General Health History

Part 5: Cardiac Health History

Part 5: Cardiac Health History

Part 6: Risk Factors

Part 7: Medications

Part 8: Mental Health

Part 9: Exercise

Part 9: Exercise

Part 9: Exercise

Part 10: Nutrition

Part 10: Nutrition

Part 10: Nutrition

Part 11: Goals

Thanks for your information!