Physical Activity Readiness and Medical Questionaire
Phone Number*
Date of Birth*
Meeting Place(s)*
Burlingame Fitness (Burlingame, CA 94010)
Woodenman Muay Thai (San Francisco, CA 94107)
Your Home Gym
Online (virtual training)
Type of Training*
1-1 training
2-1 Training
Small Group Training
Has a doctor ever said you have a heart condition? If so, explain further please.*
Do you feel pain in your chest while performing physical activity?*
In the past month, have you had chest pain when you were NOT performing any physical activity?*
What is your current occupation?*
Does your occupation involve any of the following?*
Extended periods of sitting
Extended periods of standing
Heavy mental/emotional stress
Wearing heeled/cumbersome shoes
A long commute in a vehicle
Physically strenuous activities
Do you partake in any recreational activities? Ex: sports, outdoors, leagues, etc.*
Do you have any hobbies? Ex: gardening, working on cars, knitting, etc.*
Do you have any injuries currently affecting you? If so, please describe.*
Have you had any significant injuries in the past? Please include details and an estimate of when it occured. *
Have you had any surgeries? Please describe what you had and when you had them.*
Has a medical doctor ever diagnosed you with a chronic disease? If so, please elaborate.*
Are you currently taking any medication, presciption or otherwise? If so, please elaborate.*