Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Do you have any medical follow up appointments? *

Yes

No

Has your doctor ever said your blood pressure was too high or low? *

Yes

No

Do you have any known cardiovascular problems? *

Yes

No

Has your doctor ever told you that your cholesterol was too high? *

Yes

No

Have you (or a family member) ever been told that you have diabetes? *

Yes

No

Do you have any injuries or orthopaedic problems (back, knees, etc) *

Yes

No

Do you have stiff or swollen joints? *

Yes

No

Do you have tension or soreness in any area? *

Yes

No

Are you taking any prescribed medications or dietary supplementation? *

Yes

No

Do you have any problem sleeping? *

Yes

No

Are you pregnant? *

Yes

No

Have you been advised by a doctor, physician or specialist not to perform any type of exercise/activity? *

Yes

No

In the past 4 weeks, what has been the impact of your physical and emotional health on your social activities? *

Yes

No