ISU Exercise Clinic

Current Status*

Class Time*

First Name*

Last Name*

Street Address, City, State, Zip Code*

Email Address*

Phone*

Will you need a parking pass?*

On a scale from 1 to 5, indicate your interest in working with a fitness expert (i.e., senior undergraduate student) - This is for on-campus members only

·1 indicates you are happy with your current exercise plan and do not want to work with a fitness expert.
·5 indicates you absolutely want to work with a fitness expert.

Any changes to your medical history in the past 6 months?*

Yes - Please explain
No

Medical History Comment

If you are 65 and older, are you interested in learning more about the Physical Activity and Aging Study (PAAS) being conducted in Forker?

You will receive a free comprehensive health screening annually which includes:
• Full-Body Bone Mineral Density & Bone Composition (DEXA)
• Body Shape, Posture & Balance Analysis
• Cardiovascular Function (Arterial Stiffness, Blood Pressure)
• Blood Lipids & Glucose Profiles
• Diet, Physical Activity, Fitness & Function
• Sleep Quality & Quantity
• Cognition, Mental Health & Dementia Screening

Yes
No
Already participating

Are you interested in a behavior change consultation with Dr. Kira Werstein?

Common health behaviors targeted with health coaching include:
• Exercise habituation
• Smoking cessation
• Sleep
• Stress
• Nutrition

Yes
No

Comments

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Sign up for ISU Exercise Clinic