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Fitness Questionnaire
Please fill out this form to the best of your extent for the best quality care
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Are you presently involved in a regular exercise program? If yes, please list activity, duration, frequency, and intensity.
Your answer
Do you currently smoke or have you ever smoked?
Yes
No
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Do you drink coffee or colas that contain caffeine? If yes, how much per day?
Your answer
Are you now or have you ever been on a diet? If yes, please explain.
Your answer
How active do you consider yourself?
Sedentary
Lightly Active
Moderately Active
Highly Active
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How would you describe your nutrition habits?
Good
Fair
Poor
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Please describe your knowledge of fitness?
Good
Fair
Poor
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How would you characterize your life?
Highly stressful
Moderately stressful
Low in stress
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Please list any prescribed medications you are now taking?
Your answer
Please list any over the counter medications or dietary supplements you are now taking?
Your answer
Have you had any surgery? If yes, please explain.
Your answer
Do you have any orthopedic issues with your shoulders, elbows, hands, hips, knees, neck or low back?
Your answer
Do you have any neurological conditions such as sciatica, pinched nerves, carpel tunnel, bells palsy, pins and needles, numbness, paresthesia?
Yes
No
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Check and conditions or diseases you now have or have had in the past.
Heart Attack
Stroke
Diabetes
High Blood Pressure
Low Blood Pressure
Swollen, Stiff, and/or Painful Joints
Anemia
Asthma
Emphysema
Pneumonia
Arthritis
Anxiety
Vertigo
Ulcers
Migraine
Reflux
Shortness of Breath
Fatigue and/or Lack of Energy
Tendonitis
Bursitis
Hernia
Frozen Shoulder
Please list the date of the last physical examination and results? (B/P, Heart Rate, Pulse, Glucose, Cholesterol, Thyroid, Hormone levels, ect.)
Your answer
A copy of your responses will be emailed to the address you provided.
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