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.
Do you currently smoke or have you ever smoked?
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Do you drink coffee or colas that contain caffeine? If yes, how much per day?
Are you now or have you ever been on a diet? If yes, please explain.
How active do you consider yourself?
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How would you describe your nutrition habits?
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Please describe your knowledge of fitness?
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How would you characterize your life?
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Please list any prescribed medications you are now taking?
Please list any over the counter medications or dietary supplements you are now taking?
Have you had any surgery? If yes, please explain.
Do you have any orthopedic issues with your shoulders, elbows, hands, hips, knees, neck or low back?
Do you have any neurological conditions such as sciatica, pinched nerves, carpel tunnel, bells palsy, pins and needles, numbness, paresthesia?
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Check and conditions or diseases you now have or have had in the past.
Please list the date of the last physical examination and results? (B/P, Heart Rate, Pulse, Glucose, Cholesterol, Thyroid, Hormone levels, ect.)
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