Health Screening Form
LIMITLESS PERFORMANCE
Full Name
First Name
Last Name
What is your age?
What is your weight and height?
What is your sex?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Are you pregnant or planning to conceive?
Pregnant
Trying to conceive or planning to conceive in near future
No
Email Address
example@example.com
Check the conditions that apply to you:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None
Other
If yes, do you have medical clearance for exercise from a health professional/doctor?
Check the symptoms that you' re currently experiencing (relating to a medical condition):
Chest pain
Respiratory
Cardiac disease
Psychiatric
Gastrointestinal
Weight gain
Weight loss
Are you currently taking any medication?
Yes
No
Do you use any kind of tobacco or have you ever used them (smoking, vaping, nicotine packets etc)?
Please Select
Yes
No
Describe how your currently staying active/activity level:
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Submit
Should be Empty: