Questionnaire

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Health Questionnaire

Health Questionaire

Thanks for signing up! Please take 3-5 minutes to fill out this health questionnaire so that we can learn a little bit more about you. You will be hearing from a coach soon!

* Indicates required field

Name *

First

Last

Phone Number *

How tall are you? *

How much do you weigh? *

Which program are you participating in? *

What do you want to accomplish by training here? (Ex. lose weight, improve performance, increase strength, get healthy) *

Do you smoke? *

Yes No

Do you drink alcohol? *

Yes No

Do you exercise? *

Yes No

If yes, how often? If no, when was the last time? *

Are you tired or lack energy during the day? *

Yes No

Is your sleep consistent (same time and same amount) and restful? *

Yes No

Do you drink at least 8 glasses of water per day? *

Yes No

Do you drink coffee or soda? *

Yes No

Are you allergic to anything? (Ex. food, bees, etc.) *

Yes No

If yes, what? *

Do you take prescription medications? *

Yes No

If yes, what conditions are they prescribed for? (Ex. blood pressure or heart condition) *

Do you take over the counter medication? *

Yes No

If yes, please list. *

Do you take herbal or nutritional supplements? *

Yes No

If yes, please list *

Do you take a multi-vitamin/mineral? *

Yes No

What do you eat in a typical week day (Mon-Fri)? *

What do you eat in a typical weekend day (Sat/Sun)? *

What is your occupation? *

How stressful is your job? *

Not at all Sometimes More than half of the time I want to pull my hair out

Do you participate in any sports? *

Yes No

Are they recreational or competitive? *

Recreational Competitive

Please list any sports you participate in *

Do you have back pain, knee pain or shoulder pain? *

Yes No

Do you have stiff, swollen or painful joints? *

Yes No

Have you had any broken bones or joint injuries? *

Yes No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes No

Do you have high blood pressure? *

Yes No

Do you have high cholesterol? *

Yes No

Are you epileptic or prone to seizures? *

Yes No

Do you have a cardiac condition? *

Yes No

Do you ever experience chest pain? *

Yes No

If so, when? *

Do you have asthma? *

Yes No

Do you have diabetes? *

Yes No

Have you lost consciousness or fell over as a result of dizziness? *

Yes No

Do you suffer from depression? *

Yes No

Have you had any surgeries? *

Yes No

Have you ever been told by a physician to avoid any type of exercise? *

Yes No

List any other health concerns or conditions that you have or have questions about. *

Submit

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