1. Health and Wellness Pre-Screening Questionnaire

1
New Client Information* This field is required.Please enter your first and last name, email address, and best phone number to reach you.
First Name
Last Name
Email Address
Phone Number
Height
Weight (in pounds)
Date of Birth
2
Have you ever been treated for, diagnosed as having, or currently experiencing any of the following:* This field is required.
Diabetes
High Cholesterol
Skin tumors, skin cancer or melanoma
Cancer
Any infectious progressive illness, such as Hepatitis B, Acquired Immune Deficiency
Syndrome or other conditions
Physical Therapy
Any circulatory disorder
Neuromuscular/neurological disorders such as seizures
Fainting, convulsions, recurrent headaches, dizziness
Stroke
Nervous or mental disorder
Active rheumatoid arthritis
Osteoporosis
Anti-coagulant medication
Anti-depressive medication
Hormonal treatment / Therapy
Liposuction or cosmetic surgery within the last six months
Allergies
Digestive problems
Laxatives or Diuretics
Smoking
Pregnancy
None / Not applicable
Other
3
Are you currently taking any medications / drugs that may interfere with your ability to perform rigorous exercise?* This field is required.
YESNO
4
Have you ever had heart trouble or coronary disease?* This field is required.
YESNO
5
Has your doctor / cardiologist cleared you for exercise?
YESNO
6
Please list any injuries and/or surgeries within the last 3 years that may interfere with your ability to perform rigorous exercise:
Huge
Large
Normal
Small
Ok
Ok
7
Please select the date of your most recent physical:* This field is required.
Date
Month
Day
Year
8
How many hours of sleep do you average per night?* This field is required.Please select from the list below:
1 - 4 hours
5 - 7 hours
8 hours
9+ hours
9
How many cups of water do you drink per day?* This field is required.
10
How many cups of caffeinated beverages do you drink per day?* This field is required.(Soda, coffee, tea, etc.)
11
Rate yourself on the following scales: * This field is required.
1 - Poor
2 - Decent
3 - Average
4 - Excellent
5 - Perfect
Athletic Ability
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Competitiveness
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Cardio Conditioning
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Muscular Conditioning
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Flexibility
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Athletic Ability
Competitiveness
Cardio Conditioning
Muscular Conditioning
Flexibility
1 - Poor
Row 0, Column 0
2 - Decent
Row 0, Column 1
3 - Average
Row 0, Column 2
4 - Excellent
Row 0, Column 3
5 - Perfect
Row 0, Column 4
1 - Poor
Row 1, Column 0
2 - Decent
Row 1, Column 1
3 - Average
Row 1, Column 2
4 - Excellent
Row 1, Column 3
5 - Perfect
Row 1, Column 4
1 - Poor
Row 2, Column 0
2 - Decent
Row 2, Column 1
3 - Average
Row 2, Column 2
4 - Excellent
Row 2, Column 3
5 - Perfect
Row 2, Column 4
1 - Poor
Row 3, Column 0
2 - Decent
Row 3, Column 1
3 - Average
Row 3, Column 2
4 - Excellent
Row 3, Column 3
5 - Perfect
Row 3, Column 4
1 - Poor
Row 4, Column 0
2 - Decent
Row 4, Column 1
3 - Average
Row 4, Column 2
4 - Excellent
Row 4, Column 3
5 - Perfect
Row 4, Column 4
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