Health & LifeStyle Questionnaire Name * First Name Last Name Email * Phone (###) ### #### Age Address Address 1 Address 2 City State/Province Zip/Postal Code Country Message * Emergency Contact * Physical Activity Readiness Do you ever have pains in your heart or chest? Have you ever been diagnosed with heart problems? Do you ever feel faint or have dizzy spells? Have you been diagnosed with high blood pressure? Do you smoke? Is there any reason why you should not exercise? Date of Last Physical Exam? * Do you have any serious or Chronic Illnesses? * Have you been hospitalized in the last 3 years? * Do you have any allergies? * Any chance you could be pregnant? Injuries? * Please check any of the following injuries you have had & specifics Broken Bones Muscle Strain/ Joint Pain Ligament, Tendon or Cartilage Injury Back Injury Neck Injury Low Back Pain Other Share Details Cardiovascular Risk Have any of your parents or siblings had High Blood Pressure, High Cholesterol, Diabetes, Heart Disease, or Stroke? Thank you!
