Pre-Activity Medical Questionnaire 1Personal Details2Your Goals3Emergency Contact Information4Physician Contact Information5Medical History6Activity and Exercise Profile 1. Personal DetailsName* 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your Main Contact Phone Number*Email* Date of Visit MM slash DD slash YYYY 2. Your GoalsWhat 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 InformationEmergency Contact - Name Emergency Contact - Phone 4. Physician Contact InformationName of Your Physician Physician Phone Number 5. Medical HistoryHave you ever been diagnosed with having any of the following conditions? Heart attack or angina Diabetes High blood pressure (>140/90) Low blood pressure (<100/60) High cholesterol Stroke or transient ischemic attack Lung disease Epilepsy or seizures Other neurological conditions Rheumatoid arthritis Other arthritic conditions Visual or depth perception problems Inner ear problems Osteoporosis, osteopenia, or low bone density Incontinence with exercise or stress Depression Cancer Joint replacement Other medical condition If you indicated you had any of the above medical conditions, please indicate year of onset and important details related to the specific condition(s).Have you had a bone mineral density test? Yes No Do not know or cannot recall If you have had bone mineral test, please provide the results.Do you see a physician regularly for any medical condition? Yes No If you answered yes to the question above, please describe the medical condition.Have you ever injured or experienced pain in the following areas? Neck Upper back Lower back Shoulders Wrists or fingers Elbows Hips Knees Ankles or shins Other (please describe below) If any of these conditions are currently bothering you, please provide detail.Please indicate all movements or activities that make the pain worse or better. What was the duration of the last flare up you had? Do you currently work with any of the following practitioners? Chiropractor Osteopath Massage Therapist Other If you chose "Other" from above, please specify practitioner type. If you are working with one or more of the practitioners listed above, please specify for what condition.Do you take any of the following? Omega 3 Vitamin D If you are taking any of the above items, please specify how much of each.List all medications that you currently take and indicate the condition.Medication or SupplementCondition 6. Activity and Exercise ProfileDescribe 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. Δ