Athletic Medicine and Physical Education

Physical Education

PE 707/708/709

PE 134

PE 325/332/470

Rio Hondo College

East Los Angeles College

Student Info

Calorie Count

Caloric Values

Circuit

Arby's	Boston Market	Burger King	Carl's Jr
Chick-fil-a	Chuck E Cheese	Church's Chicken	Dairy Queen
Del Taco	Denny's	Domino's	In-n-Out
Jack-in-the-Box	KFC	Koo Koo Roo	Krispy Kreme
Little Ceasar's	McDonald's	Panda Express	Papa John's
Pizza Hut	Quizno's	Sonic	Starbucks
Subway	Taco Bell	Spaghetti Factory	Wendy's

Student Information:

E-mail:
Name:	First then Last name.
Student ID:	Only use numbers. No spaces, hyphens or parenthesis.
Which class are you enrolled:
Are you repeating this course?
Address:
City:
Zip:
Home Phone:	Only use numbers. No spaces, hyphens or parenthesis.
Cell Phone:	Only use numbers. No spaces, hyphens or parenthesis.
In case of an emergency, who should we contact (preferably a parent)?
Name of Contact:	First and Last Name
Contact Phone:	Only use numbers. No spaces, hyphens or parenthesis. You should use their cell phone.
Relationship:
What is your resting heart rate:	Take your heart rate for one full minute. Your resting heart rate should be between 60 and 90 beats per minute.
How much do you weigh?
How tall are you?	Feet Inches
Date of Birth:	Only numbers! Use the following format: "mmddyy"
Age:
Gender:
Do you take any medications?:
Please list all the medications you are currently taking:
Do you have any allergies?
Please list all of your allergies:
Do you have any medical problems?
Please list all of your medical problems:
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
If yes, explain:
Do you feel pain in your chest when you do physical activity?
If yes, explain:
In the past 30 days, have you had chest pain when you were not doing physical activity?
If yes, explain:
Do you lose your balance because of dizziness or do you ever lose consciousness?
If yes, explain:
Do you have bone or joint problems that could be made worse by a changing your physical activity?
If yes, explain:
Is your doctor currently prescribing medication for your blood pressure or heart condition?
If yes, explain:
Do you have diabetes?
If yes, explain:
Do you have asthma? If yes, you must carry your inhaler with you at all times, NO EXCEPTIONS!
If yes, explain:
Are you pregnant?
If yes, explain:
Do you have problems with seizures?
If yes, explain:
Do you smoke cigarettes?
If yes, how many per day?
Do you, or any member of your family, have a history of heart disease?
If yes, explain:
Do you know of any other reason why you should not do physical activity?
If yes, explain:

Back to the Top