Daisey Physical Therapy and The Center for Human Performance

Cervical/Neck

Shoulders/Rotator Cuff

Knees/Patella

Hips

Elbow and Wrist

Ankle and Foot

BUILD A TOTAL BODY FITNESS PROGRAM

First Name:
Age:
Gender:

You have the option to select between 4 different types of Total Body Fitness Programs.

The four programs are different primarily with respect to how your exercises are spaced within the program. Program #1 and 2 are recommended for beginners, while #3 and #4 are for intermediate-level exercisers. All programs can be completed in less than one hour.

Select the format that appeals most to you:

Program One: 3 times per week Warm-up: 5 min Weight-training: 25 min Total body Cardiovasular: 20 min Stretching: 5 min	Program Two: 3 times per week Warm-up: 5 min Weight-training: 15 min Upper body Cardiovasular: 5 min Weight-training: 10 min Lower body Cardiovasular: 5 min Weight-training: 5 min Abdominals Cardiovasular: 10 min Stretching: 5 min
Program Three: 4 times per week Warm-up: 5 min Weight-training: 25 min Upper body on 2 of the 4 days; 25 min Lower body on the other 2 days Cardiovascular: 20 min Stretching: 5 min	Program Four: 4 times per week Warm-up: 5 min Weight-training: 15 min Upper body on 2 of the four days; 15 min of Lower body on the other 2 days Cardiovasular: 5 min Weight-training: 10 min Upper body on 2 of the 4 days; 10 min Lower body on the other 2 days Cardiovasular: 5 min Weight-training: 5 min Abdominals Cardiovasular: 10 min Stretching: 5 min

We need to get some information from you to be
able to customize your total-body fitness program

When was the last time you exercised AT ALL for a sustained period of at least 3 months?


CARDIOVASCULAR
Height:	feet inches
Weight:	pounds
Total Cholesterol Level:	mg/dl (Leave blank if unsure)
Resting Heart Rate: (How do I find my resting heart rate?)	Beats per minute (bpm)
Resting Blood Pressure:	over mmHG (Leave blank if unsure)

Check which cardiovascular exercises you are most interested in adding to your program or that you most enjoy performing:

Stationary bike
Recumbent bike
Outdoor bike
Treadmill walking
Treadmill jogging
Outdoor walking
Outdoor jogging

Stairclimber
Elliptical bike
Cross Country Ski simulator
Upper body ergometer
Rowing machine
Swimming
Aerobics

WEIGHTLIFTING

We need to get an idea of what your starting point is.

1) Under each category below, click the circle next to the name of the exercise you are more comfortable performing.

2) Fill in the approximate amount of weight that you can lift for 10 repetitions to the point of fatigue for each exercise you chose (i.e. if you choose chin-ups or push-ups, enter the number of repetitions you are able to perform to fatigue). Fatigue means not quite to complete muscular failure, but within 1-2 reps of failure.

If you do not know how much weight you can lift in some of these exercises, don't worry. Leave it blank. DaiseyPT.com will build a more conservative program.

At least tell us which exercises you are most comfortable performing.

(click exercises to view them)
Flat Bench Press/Chest
Barbell Dumbbell	lbs x 10 reps
Push-ups	reps
Upper Back
Lat-Pulldown Compound Row	lbs x 10 reps
Chin-ups	reps
Biceps Curl
Barbell (two hands) Dumbbell (single arm)	lbs x 10 reps
Triceps
Machine Pressdowns Lying Tricep Extensions	lbs x 10 reps
Shoulder (Military) Press
Barbell (or machine) Dumbbell	lbs x 10 reps
Legs
Leg Press Squat	lbs x 10 reps
Abdominals
How many crunches can you perform to fatigue?	reps
How far can you jog continuously before you fatigue?	miles

STRETCHING

I need a BEGINNING stretching program (I am generally inflexible and am unable and touch my fingertips to my toes).
I need an INTERMEDIATE stretching program (I used to be very flexible, but have lost a great deal due to inactivity).
I am ready for an ADVANCED stretching program (I stretch routinely and would like to update my program and enhance my flexibility beyond its current level).

PAST INJURIES

Check any of the areas in which you experience recurrent pain (mild to severe) or any area in which you have been diagnosed with an injury or medical condition:

Neck
Middle Back
Lower Back - frequent strains
Lower Back - pain as a result of a disc herniation
Lower Back - spondylolisthesis

Hip - general
Hip - arthritis and hip replacement
Knee - arthritis or meniscus
Knee - ACL
Knee - Pain associated with your kneecap (Patellofemoral)

Shoulder - general strains (i.e. tendonitis, bursitis)
Shoulder - rotator cuff surgery, instability or dislocation
Elbow
Wrist
Ankle/Foot

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The information contained in this web site is not a substitute for in-person, hands-on medical advice
or treatment. Daisey Physical Therapy recommends you consult with your physician or health care professional.