FABZFIT QUESTIONNAIRE
This form is for FABZFIT clients to complete.
Email address *
Name *
Your answer
Date *
MM
/
DD
/
YYYY
Date of Birth *
Your answer
Address (City, State, Zip) *
Your answer
Please check the box that is appropriate *
Yes
No
Are you overweight?
Are you under a lot of stress?
Do you drink excessively?
Do you smoke cigarettes?
Are you more than 35 years old?
Any health conditions that the trainer should be aware of? Describe in detail *
Your answer
Has your doctor ever said you have heart trouble? *
Please indicate if you have a history of the following: *
yes
No
Heart attack
Bypass or cardiac surgery
Chest discomfort with exertion
High blood pressure
Rapid or runaway heartbeat
Skipped heartbeat
Rheumatic fever
Phlebitis or embolism
Shortness or breath w/ or wo /exercise
Fainting or light-headedness
Pulmonary disease or disorder
High blood fat (lipid) level
Stroke
Recent hospitalization for any cause. List specifics
Orthopedic problems (including arthritis) List specifics
Medical information *
Yes
No
Has your doctor ever said your blood pressure was too high?
Has your doctor ever told you that you have a bone or joint problem that has been or could be made worse by exercise?
Are you over the age of 65?
Are you unaccustomed to vigorous exercise?
Are you under the care of a physician, chiropractor, or other health care professional . for any reason? Yes or No. If yes, List reason in space provided. *
Your answer
Musculoskeletal Information / please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains, fractures, surgery, back pain or general discomfort. Please explain in the space provided. *
Required
Lifestyle, Dietary Factors, Cardiovascular *
Low
Medium
High
Occupational Stress Level:
Energy Level:
Caffeine Intake/Daily
Colds Per Year:
Gastrointestinal Disorder
Hypoglycemia
Thyroid Disorder
Pre/Postnatal
High Blood Pressure
High Cholesterol
Hyperlipidemia
Heart Disease
Heart Attack
Angina
Hypertension
Stroke
Gout
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