Wufoo

Health Questionnaire

Complete Below Form.

Name * First Last
Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email *
Phone * - (###) - ### ####
Date * / MM / DD YYYY
Does your physician approve of your participation in this exercise program? *
Yes No
Are you taking any medications that affect your vital signs (heart rate, blood pressure, breathing, etc.) or physical performance? *
Yes No
Do you know or have you had in the past: *
History of heart problems in the immediate family Cigarette, cigar, or pipe smoking habit Increased blood pressure Increased total blood cholesterol (>200 mg/dL) Diabetes mellitus History of heart problems, chest pain, or stroke History of breathing or lung problems Muscle, joint, or back disorder, or any previous injury still affecting you Hernia or any condition that may be aggravated by lifting weights? Any chronic illness or condition Obesity (more than 20% over ideal body weight) Recent surgery (last 12 months) Pregnancy (now or within last year) Difficulty with physical exercise Advice from physician not to exercise N/A
Rate your current fitness level from 1-10 (10 being the fittest).
Do Not Fill This Out