Health and Fitness Questionnaire
Saturday, March 14th, 2009Copy, print and complete.
Health And Fitness Questionnaire
Contact Information
Name:_______________________
Age:______
Date:________________________
Occupation:__________________________
Contact number:__________________________
Email Address:__________________________
Primary health care provider:__________________________
Provider’s contact number: __________________________
Health History
1. Do you smoke? Yes No
If you answered yes, how much do you smoke?________
2. Has your doctor ever said your blood pressure was too high or low? Yes No
3. Have you (or a family member) ever been told that you have diabetes? Yes No
4. Do you have any cardiovascular problems (Heart disease, previous
Heart attack, atherosclerosis, abnormal electrocardiogram)? Yes No
If yes, please describe:________________________________
5. Has your doctor ever told you your cholesterol level was high? Yes No
6. Are you overweight? Yes No
If you answered yes, how much are you overweight?_________
7. Current weight:___________
8. Do you have any injuries or orthopaedic problems? Yes No
9. Are you taking any prescribed medications or dietary supplements? Yes No
If so, please describe:____________________________________
10. Are you pregnant or postpartum less than six weeks? Yes No
11. Date of last physical examination:__________________________
12. Do you have any other medical conditions or problems not previously
Mentioned? Yes No
If yes, please describe:_____________________________________
13. Were did you hear about us? Did anyone refer you, if so, who?:__________________________
14. List your goals :__________________________________________________________________
___________________________________________________________________________________
*If you answered “Yes” to questions 2 or 4, a doctors note is required before you can enter into a fitness program. A doctors note may be required for any other reason to be determined upon day of consultation.