HEALTH, ACTIVITY, AND DIETARY HISTORY QUESTIONNAIRE
Form is required for fitness and health training/coaching
Email address *
Full Name *
Your answer
Health History
please complete to the best of your ability
Are you currently on medication? *
Describe:
Your answer
Check all the conditions you have or have had *
Required
Describe your condition
Your answer
Have you ever been injured in any of the following areas? *
Required
Describe your injury (date, type, etc.)
Your answer
If yes, explain:
Your answer
Are you currently under the care of a physician for any reason at all? *
Do you smoke cigarettes? *
If yes, how much?
Your answer
Do you know of any physical condition that you have that could be aggravated by exercising or exerting yourself? *
If yes, explain:
Your answer
Are you taking any medication which could cause a reaction while exercising? *
If yes, explain:
Your answer
Does your doctor know that you are beginning a new exercise program? *
If your doctor knows that you are beginning a new exercise program, does he/she object? *
If yes, why:
Your answer
I know of no physical or medical condition which I, or my Doctor, feel could be aggravated by my using the equipment and facilities or, participating in activities sponsored by Melissa Lopez Health and Fitness Enterprises, “Club”. I agree to advise Melissa Lopez Health and Fitness Enterprises in writing if any of the above information changes or if my Doctor advises me to stop, reduce, or otherwise adjust my exercise regimen at or with the Club. I will advise Melissa Lopez Health and Fitness Enterprises immediately if I injure myself in any way while on Club property or during Club time. The information I have given on this form is, to the best of my knowledge, complete and accurate. *
Required
DATE *
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