Medical Questionnaire
Name*
Address*
Date*
Height Feet & Inches*
Weight (pounds)*
Age*
Physician's Name*
Phone*
Has your doctor restricted your activity levels?*
Yes
No
Does your chest hurt during physical activities?*
Yes
No
Have you had chest pain without activity?*
Yes
No
Ever lose balance/consciousness due to dizziness?*
Yes
No
Any body problems that can worsen with activity?*
Yes
No
Any blood pressure or heart condition medications*
Yes
No
Any other reasons for limited physical activity?*
Yes
No
What is your current occupation?*
Does your job require extended periods of sitting*
Yes
No
Does your job require repetitive movements?*
Yes
No
If Yes, please explain
Does your job require you to wear heeled shoes?*
Yes
No
Does your job cause you anxiety (mental stress)?*
Yes
No
Do you partake in any recreational activities*
Yes
No
If Yes, which ones?
Do you have any hobbies*
Yes
No
If Yes, what are they?
Have you ever had any pain or injuries*
Yes
No
If Yes, please provide details
Have you ever had any surgeries?*
Yes
No
Please explain if Yes
Has a medical doctor ever diagnosed you with:
A chronic disease
Coronary artery disease
Hypertension (high blood pressure)
High cholesterol
Diabetes
If yes to any, please explain
Are you currently taking any medication?*
Yes
No
If yes, please list
Exercise and fitness goals*
3 things to reach my exercise and activity goals*
Diet and Nutrition Goals*
3 things to reach my Diet and Nutrition goals*
Which program are you interested in ?*
12 week Transformation Program
Small Group Training
1 on 1 Personal Training
1 on 1 Virtual Training
Small Group Virtual Training
Mobile workout App
Athletic Strength & Conditioning Training
Youth Training Program
Weightlifting for beginners
Motivation to reach my GetFIT goals:*
How did you hear about us ?*
Social Media Handle