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Health Questionnaire
Complete this forum prior to booking a fitness program to determine if you should have a medical evaluation before participating in strenuous activity
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Has your Doctor ever said that you have a heart condition that you should only perform physical activity recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you perform physical activity?
*
Yes
No
In the past month, have you had chest pain when you are not performing any physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
*
Yes
No
Do you have any other reason why you should not engage in physical activity?
*
Yes
No
If you answered yes to any of the previous questions please explain:
What is you current occupation?
Does your occupation require extended periods of sitting?
*
Yes
No
Does your occupation require extended periods of repetitive motion?
*
Yes
No
Does your occupation require you to wear shoes with a heel (dress shoes)?
*
Yes
No
Does your occupation cause you anxiety (mental stress)?
*
Yes
No
If you answered yes to any of the previous questions please explain:
Do you partake in any recreational activities (golf, tennis, etc.)? (If yes, please explain.)
Do you have any hobbies (reading, gardening, working on cars, etc.)? (If yes, please explain.)
Have you ever had any pain or injuries (ankle, knee, hip, shoulder, etc.)? (If yes, please explain.)
Have you ever had any surgeries? (If yes, please explain.)
Has a medical doctor diagnosed you with chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.)
Are you currently taking any medication? (If yes, please explain.)
What does you diet consist of? (List Below) Breakfast, Lunch, Dinner, Snacks
How frequently do you eat?
What is your daily water consumption/ intake?
Do you have any diet restrictions? (i.e. no red meats, pescatarian diet, peanut allergies)
What are your fitness goals? (Be Specific) (i.e. I would like to lose 20 lbs by June)
Do you have any areas you would like to target specifically? (i.e. arms, stomach)
How frequent do you work out?
What time works best with your current schedule?
Would you like a home gym workout program?
Submit
