To help me support your health and fitness journey safely and effectively, please take a few moments to complete this short questionnaire.

Your responses will help me understand your current health status, physical activity levels, and any relevant medical history. This information allows me to tailor an approach to your individual needs and ensure you exercise safely.

All information you provide will be treated with the utmost confidentiality and used only for the purpose of your health and fitness assessment.

Your details

Medical History

Please provide details of your medical history.
Include any relevant conditions such as:

  • Heart condition

  • High blood pressure

  • High cholesterol

  • Diabetes or pre-diabetes

  • Asthma or breathing problems

  • Joint pain or arthritis

  • Back pain or spinal issues

  • Any recent surgery (within the past 12 months)

  • If you are currently pregnant or recently postpartum

  • Any medications you are currently taking

Lifestyle & Activity

How would you rate your daily activity level? *

Goals

What are your top 3 fitness goals?

Nutrition & Habits

How would you rate your eating habits?
How would you rate your current stress level?

Additional Information

Waiver & Acknowledgment

I confirm that the above information is accurate to the best of my knowledge. I understand that participation in a fitness program carries inherent risks and agree to consult a physician before beginning any new exercise routine.

Select Yes to confirm you acknowledge of this waiver
Thank you for completing your Health Questionnaire.
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