[How to Add and Set Up the Draw on Image Widget on Your Form]

Medical Questionnaire
Full Name

First NameLast Name
E-mail Address
example@example.com
Contact Number
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Date of Birth

DayMonthYear
Has your doctor ever said your blood pressure was too high or too low?

YesNo
Please provide details.
Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?

YesNo
Please provide details.
Has your doctor ever told you that your cholesterol was too high?

YesNo
Please provide details.
Have you (or a family member) ever been told that you have diabetes?

YesNo
Please provide details.
Do you have any injuries or orthopedic problems (back, knees, etc)?

YesNo
Please provide details.
Do you have stiff or swollen joints?

YesNo
Please provide details.
Do you have tension or soreness in any area?

YesNo
Please provide details.
Are you taking any prescribed medications or dietary supplementation?

YesNo
Please provide details.
Do you ever have problems sleeping?

YesNo
Are you pregnant or post-partum (< 6 weeks)?

YesNo
Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?

YesNo
Please provide details.
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?

YesNo
Color in the areas where you currently feel pain.
Should be Empty:

Medical Questionnaire