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first responders
LIFESTYLE AND FITNESS QUESTIONNAIRE
Client information:
*
Indicates required field
Status:
*
Miss
Mr.
Mrs.
Ms.
Name
*
First
Last
Date of Birth (mm/dd/yyyy)
*
mm/dd/yyyy
Phone Number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Occupation
*
EXISTING medical CONDITIONS:
Please check the appropriate conditions:
*
Diabetes
Obesity
Ulcer
Anemia
Epilepsy
Eye problems
Asthma
Cholesterol
Hearing loss
Arthritis
Hernia
Thyroid problems
Heart Condtion
family health history:
1. Check any family member who died of a heart attack before age 50:
*
Father
Mother
Brother
Sister
Grandparent
2. List any major illness your immediate family suffers from:
*
Medications:
Are you currently taking any medications?
*
Yes
No
If you checked YES, please list the medication and for what condition:
1. Medication
*
1. Condition
*
2. Medication
*
2. Condition
*
3. Medication
*
3. Condition
*
For women only:
1. Are you pregnant?
*
Yes
No
If yes, then
How many months?
*
Approx. date of delivery
*
2. Have you been told to restrict your activities during pregnancy?
*
Yes
No
3. How many pregnancies have you had?
*
4. Would you consider them normal?
*
Yes
No
5. Did you exercise during pregnancy?
*
Yes
No
6. Date of last pregnancy:
*
7. Was it full term?
*
Yes
No
Injuries
Do you have any pain or have you injured any of the following areas?
*
Neck
Elbow
Upper Back
Wrist R/L
Lower Back
Knee L/R
Shoulder R/L
Ankle R/L
Current Activity Levels
1. Do you consider yourself to be active?
*
Yes
No
How often do you exercise?
*
0
1
2
3
4
5
6
7
days per week
Lifestyle
1. Rate your stress on a daily basis:
*
Low
Moderate
High
2. How much sleep do you average each night?
*
4
5
5
7
8
9
10
3. Do you smoke?
*
Yes
No
4. What is your alcohol consumption?
*
None
Mild
Moderate
Frequent
nutritional habits
1. Do you follow a special diet?
*
Yes
No
2. How would you rate your eating habits?
*
Poor
Ok
Good
Very Good
3. Is weight loss one of your primary exercise goals?
*
Yes
No
4. What are your other fitness goals?
*
How did you hear about our first responders program?
*
Submit
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Programs
Sports/Team Training
Personal Training
Online Programs
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About
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Contact