Re6el Fit Client Questionnaire
Please complete this form before scheduling your workout session.
Your Physicians Name & Number (in case of an emergency)
Emergency Contact Name & Number
Are you taking any medications, supplements, etc? If so please list medication and dose, along with reason.
Does your physician suggest in participating in exercising program?
Describe any physical activity you do and how often:
Please check all that apply to you currently:
No preexisting conditions
Advised by your PCP not to exercise
History or heart problems, chest pain or stroke
History of heart problems In you’re immediate family High blood pressure
History of shortness of breathing
Cigarette smoking habit
Diabetes or metabolic syndrome
Recent vehicular accident
Muscle, joint, or back disorder or any precious injury still affecting you
If you read, agree and understand the consent terms found at:
, please type your full name below. This will be considered your electronic signature.
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