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To help us better serve you please
take a moment to complete the questionnaire below. All personal information received by Forever Fit is kept confidential.
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Name
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Email
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Phone #
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Address
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City
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State/Province
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Zip/Postal Code
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Date of Birth (dd/mm/yy)
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Past History: Have you had OR do you presently
have any of these conditions?
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Arthritis
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Osteoporosis
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Depression
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High blood pressure
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low blood pressure
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Heart disease
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Weight problems
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Fybromyalgia
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Asthma
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Diabetes
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Recent Operations
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Injury back or knees
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Other
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Family History:
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Heart Disease
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High Blood pressure
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Diabetes
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Heart Attack
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Other major illness
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Explain Checked Items
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Activity History:
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What goals are you looking to accomplish?
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Are you participating in a regular exercise program at this time?
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YES NO
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If yes, briefly describe
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Do you have any bone or muscle injuries that may interfere with exercising?
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Are you currently taking any medication?
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YES NO
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If yes, please list
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Other comments:
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Forever Fit Health / Medical Questionnaire
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