Pre-Activity Medical Questionnaire - Function to Fitness

Pre-Activity Medical Questionnaire

1Personal Details

2Your Goals

3Emergency Contact Information

4Physician Contact Information

5Medical History

6Activity and Exercise Profile

1. Personal Details
Name*
First Last
Date of Birth
MM slash DD slash YYYY

Enter your date of birth.
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Your Main Contact Phone Number*
Email*
Date of Visit
MM slash DD slash YYYY

2. Your Goals
What are the health and fitness goals that you want me to help you with?*

Your goals should specific, measurable, attainable, realistic and timely.
My most important goal is ...

3. Emergency Contact Information
Emergency Contact - Name
Emergency Contact - Phone

4. Physician Contact Information
Name of Your Physician
Physician Phone Number

6. Activity and Exercise Profile
Describe your exercise profile over the past three (3) months.*
Please indicate how many minutes per day, how many days per week, and the type of physical activity or exercise.
Briefly describe your level of participation in sports and physical activities from childhood to today.
Thank you for completing the Pre-Activity Medical Questionnaire. The Consent Form (which is much shorter) is next.