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Health Questionnaire
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YOUR APPOINTMENT HAS BEEN SET
Healthcare Questionnaire
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Full Name
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Phone Number
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Email
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What PRESCRIPTION Medication do you take?
(Required)
Acid-Reflux / GERD
Arthritis Pain
Asthma, COPD / Breathing Issues
Autoimmune Disorder
Coronary Heart Disease
Diabetes / Pre-Diabetes
High Blood Pressure
High Cholesterol
Neurological Disorder
Sleep Disorder
Medication for other conditions
NONE of the Above
How Concerned are you about failing?
(Required)
Select an option from the dropdown
Not at all concerned
Somewhat concerned
Very concerned
Are you currently experiencing any physical limitations that could affect your training plan?
(Required)
What PRESCRIPTION Medication do you regularly take?
(Required)
Acid-Reflux / GERD
Arthritis Pain
Asthma, COPD / Breathing Issues
Autoimmune Disorder
Coronary Heart Disease
Diabetes / Pre-Diabetes
High Blood Pressure
High Cholesterol
Neurological Disorder
Sleep Disorder
Medication for other conditions
NONE of the Above
Do you smoke tobacco products?
No
Yes
Which of the following health conditions (if applicable) have you been told that you have EVER had?
(Required)
Arthritis
Cancer
Depression
Diabetes
Heart
Hearing Impairment
Are you able to walk 10 minutes on your own?
(Required)
Yes, no asisstance
Yes, with asisstance
Not, not at all
Rate your experience with exercise
(Required)
Beginner
Intermediate
Advanced
What are your health / fitness goals?
(Required)
Reduce Joint Pain
Lower Cholesterol
Increase Flexibility
Lower Blood Pressure
Increase Energy Levels
Strengthen Lower Back
Increase Strength and Mobility
Manage Blood Sugar Levels
Increase Physical Confidence
Reduce Stress
Maintain / Strengthen Surgical Recovery
Weight Loss
Postural Improvement
Kidney or Bladder Disease
Lung
Memory Problems
Mobility Problems
Stroke
Substance Abuse
Vision Impairment
NONE of the Above
How would you rate your health?
(Required)
Excellent
Very Good
Good
Fair
Poor
What type of exercises are your interested in?
(Required)
Balance exercises that help prevent falls
Flexibility exercises that stretch your muscles and help your body stay limber
Strength exercises that make your muscles stronger and toned
Endurance or aerobic activities that increase your breathing and hearth rate
If currently exercising please describe your activities
(Required)
