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Health Questionnaire

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Please complete the form below prior to your first appointment. If you need assistance, please let us know. (If you’re having trouble with the online form: you may download and complete a Word version instead. Click here to download.)

You must complete all required fields and click the SUBMIT button at the bottom of this form for us to receive. If you miss a required field, it will not submit, and will highlight the missed field in red.
You may use the SAVE & FINISH LATER button at the bottom if you are unable to complete the form in one sitting. When you click the button, you will receive a link to continue later. You can choose to have this link emailed to you.

Today's Date(Required)

MM slash DD slash YYYY

Full Name(Required)

Email(Required)

Gender(Required)

Male

Female

Other

Prefer not to answer

Are you currently under the care of a doctor?(Required)

Yes

No

Provide the type, name, and phone number of your doctor(Required)

What is the date and reason you last saw your doctor?(Required)

Have you performed planned, structured physical activity for at least 30 minutes, at moderate intensity, on at least 3 days per week, for at least the last 3 months?(Required)

Yes

No

If yes, what has your prior physical activity consisted of?(Required)

Have you ever had a heart condition or coronary artery disease?(Required)

Yes

No

If yes, please explain:(Required)

Do you have a family history of heart conditions or coronary artery disease?:(Required)

Yes

No

If yes, please explain:(Required)

Do you have a history of high blood pressure (above 140/90)?(Required)

Yes

No

If yes, are you currently under the care of a doctor for this condition?(Required)

Do you have diabetes?(Required)

Yes, Type 1 Diabetes

Yes, Type 2 Diabetes

No

If yes, please provide name and phone number of your doctor:(Required)

If yes, what was the date and result of your last HbA1C?(Required)

Do you worry about your weight?(Required)

Yes

No

If yes, please explain:(Required)

Are you trying to or has anyone recommended that you gain or lose weight?(Required)

Yes

No

If yes, please explain:(Required)

Are you currently on a special diet?(Required)

Yes

No

If yes, please explain:(Required)

Has your doctor ever said you have high cholesterol?(Required)

Please list any prescribed medications you are currently taking(Required)

Please list any over the counter medication or dietary supplements you are taking:(Required)

Please list any allergies (ie. medicine, pollen, food, stinging insects):(Required)

Please list any hospitalizations or surgical procedures within the past 3 years:(Required)

Have you had liposuction or cosmetic surgery within the last six months? If yes, what was the date or type?(Required)

Are you currently under the care of a physical therapist?(Required)

Yes

No

If yes, for what condition?(Required)

Do you have trouble sleeping?(Required)

Yes

No

How many hours of sleep do you average per night?(Required)

Do you wear eyeglasses or contacts?(Required)

How many cups of coffee do you drink a day?(Required)

How many sodas do you drink a day?(Required)

How much water do you drink a day?(Required)

Do you drink alcohol? If yes, include approximately how many drinks per week:(Required)

Do you use tobacco products? If yes, include what type and how much/frequent?(Required)

Have you ever participated in a diet and/or nutrition program? *(Required)

Yes

No

If yes, what was the date and type of dietary program?(Required)

If yes, what were your goals and did you achieve them?(Required)

Do you currently take laxatives and/or diuretics?(Required)

Yes

No

If yes, what type and for how long?(Required)

Do you currently use a fitness tracker?(Required)

Yes

No

If yes, which one?(Required)

What would you like to change about your health and/or fitness? *(Required)

Have you ever been treated for, diagnosed as having, or currently suffering from any of the following? Check all that apply(Required)

Skin condition, skin cancer or melanoma

Other Cancer

Any infectious disease, such as Hepatitis B, Human Immunodeficiency Virus, Acquired Immune Deficiency Syndrome, COVID-19 or other conditions

Anemia

Circulatory disorders

Neuromuscular/neurological disorders such as neuropathy, multiple sclerosis, seizures, Parkinson’s, Alzheimer’s, etc.

Fainting, cramping, dizziness, or activity intolerance

Stroke or Transient Ischemic Attack (TIA)

Mental health disorders such as anxiety, depression, bipolar, etc.

Rheumatologic diseases, such as lupus, psoriasis, rheumatoid arthritis

Osteopenia or Osteoporosis

Osteoarthritis

Pregnancy

Addiction

Pulmonary or breathing issues such as asthma, pulmonary fibrosis, COPD

Fibromyalgia

Hormone deficiency and/or Menopause

Obesity

Thyroid disease

Physical Disability

None of the above

Please provide an explanation and corresponding date(s) for anything you checked on the previous question.(Required)

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