Health Questionnaire

health QUESTIONNAIRE

This health questionnaire is designed for me to ensure I am training you safely and with your specific interests in mind. Thank you for taking the time to answer.

First Name

Last Name

Phone

Date of Birth

What are your fitness goals?

Do you have any exercise experience?

What, if any, are some exercises that you love?

What, if any, are some exercises that you despise?

What are areas of pain for your body, if any, that occur when engaging in exercise?

Have you had any recent injuries that could be made worse with exercise?

Do you often lose your balance due to dizziness?

Yes

Describe your experience.

Has your doctor ever said that you have a heart condition or high blood pressure?

Yes

Have you ever been diagnosed with a chronic medical condition?

Yes

What is your current medication plan, if any, for this condition?

How would you describe your diet?

Today's Date

I declare that the above information is true and correct to the best of my knowledge.

We got your response. Thank you for submitting!

health QUESTIONNAIRE

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