Medical Questionnaire
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact Number
Format: (000) 000-0000.
E-mail Address
example@example.com
Do you have any known blood pressure problems?
Yes
No
Please provide details.
Do you have any known cardiovascular problems?
Yes
No
Please provide details.
Do you have any known respiratory problems?
Yes
No
Please provide details.
Have you been diagnosed with diabetes or have trouble with low blood sugar?
Yes
No
Please provide details.
Do you any known allergies?
Please provide details.
Do you have any injuries or orthopedic problems, past or present?
Yes
No
Please provide details.
Are you taking any prescribed medications or dietary supplementation?
Yes
No
Please provide details.
How would you rate your quality of sleep on a scale of 1 - 5, 5 being the best?
1
2
3
4
5
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?
Yes
No
Please provide details.
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?
Yes
No
Please provide details.
I have filled this out to the best of my knowledge.
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