Fit Chick Express
Health History Questionnaire
Regular physical activity is safe for most people. However, some individuals should check with their doctor before they start an exercise program. To help us determine if you should consult with your doctor before starting to exercise with Fit Chick Express, please read the following questions carefully and answer each one honestly. All information will be kept confidential. Please check YES or NO.
Name
Your answer
Email
Your answer
Phone Number
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
Do you have a heart condition?
Have you ever experienced a stroke?
Do you have epilepsy?
Are you pregnant?
Do you have diabetes?
Do you have emphysema?
Do you feel pain in your chest when you engage in physical activity?
Do you have chronic bronchitis?
In the past month, have you had chest pain when you were not doing physical activity?
Do you ever lose consciousness or do you ever lose control of your balance due to chronic dizziness?
Are you currently being treated for a bone or joint problem that restricts you from engaging in physical activity?
Has a physician ever told you or are you aware that you have high blood pressure?
Has anyone in your immediate family (parents/siblings) had a heart attack, stroke, or cardiovascular disease before age 55?
Has a physical ever told you or are you aware that you have a high cholesterol level?
Are you currently exercising LESS than 1 hour per week?
If you answered no, please list your activities:
Your answer
Are you currently taking any medication?
Please list the medication and its purpose:
Your answer
Have you had any serious or chronic illness, surgery, chronic virus, infection, or traumatic accidents?
Please describe:
Your answer
Have you had any injuries within the past five years?
Please describe:
Your answer
Where did you learn about Fit Chick Express?
Your answer
If you were referred by a member, please let us know who we should thank:
Your answer
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