Physical Readiness, General Lifestyle, and Medical History Questionnaire
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Name: *
Email: *
Phone Number: *
Date of Birth: *
Meeting Place(s)
SAKA Package Desired:
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Physical Readiness
Please select "Other" to explain how a "Yes" answer has been addressed and cleared by your doctor
Has a doctor ever said you have a heart condition?   *
...that you should only perform physical activities recommended by a doctor?
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing any physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *
Do you know of any other reason why you should not engage in physical activity? *
If you have answered "Yes" to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered "Yes" to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Please obtain a note from physician if you have been cleared to exercise and/or engage in strenuous physical activity.

General Lifestyle
What is your current occupation?
Does your occupation involve:
check all that apply
Does your occupation involve extended periods of repetitive motion?
If so, please explain.
Do you partake in any recreational activities? If yes, please explain
e.g. team sports, individual sports, outdoor sports/activities, etc.
Do you have any hobbies? If yes, please explain.
e.g. reading, gardening, working on cars, etc.
Medical History
Please answer the following as thoroughly and detailed as you can.
Have you ever had any pain or injuries? If yes, please explain. *
e.g. ankle, knee, hip, back, shoulder, etc.
Have you ever had any surgeries? If yes, please explain. *
Have a medical doctor ever diagnosed you with a chronic disease? If yes, please explain. *
e.g. coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, diabetes, etc.
Are you currently taking any medication? If yes, please explain. *
And finally...
Let's schedule our first meeting. How would you like me to contact you?
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How did you hear about SAKA Fitness?
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Any other notes you have for me?
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