Health Survey - End Rezults Fitness

End Rezults Health Questionnaire

Fill Out The Health Questionnaire For An Accurate Consultation

Full Name

Date

Address

City

Zipcode

Cell Phone

Occupation

Business Phone

Age

D.O.B

Weight

Height

Activity Level

Marital Status

Do You Have Children?

Emergency Contact Name

Relationship With Emergency Contact

Emergency Contact Address

Emergency Contact City

Emergency Contact Zipcode

Emergency Contact Cell Phone

How Did You Hear About Us?

Email Address

Have You Ever Had A Personal Trainer?

If So, Where?

Symptoms: Check All That Apply (Leave Blank If Inapplicable)

Has your doctor ever said you have heart trouble, heart palpitation, coronary artery disease, or high blood pressure?

Do you frequently experience pain or discomfort in the chest or heart area?

Do you suffer dizziness or fainting?

Do you have any difficulty breathing?

Do you suffer from swollen ankles (due to circulation problems or metabolic condition?)

Do you suffer from shortness of breath at rest or upon mild exertion?

Risk Factors

(Check Box If Applicable) Has a physician ever diagnosed you as having high blood pressure (>160/90), or are you on blood pressure medication?

BP Measurement

Enter Your Cholesterol Number (mg/dL)

Is The Value Greater Than 240mg/dL?

Do You Smoke?

If You Do Smoke, How Many Cigarettes Per Day?

Are Either Of Your Parents Overweight?

Do You Suffer From Diabetes?

Has Anyone In Your Family Suffered From Coronary Or Atherosclerotic Disease Prior To The Age Of 55?

Are You Now, Or Do You Think That You Are Pregnant?

Medication / Limitation / Past medical history

List The Conditions That Your Medication Treats (If Applicable)

Do You Have Allergies?

If So, What Are They?

Do You Have Any Physical Limitations That Would Limit Your Ability To Exercise?

Please List All Injuries, Surgeries, and/or Medical Conditions (Past and Present) And The Year In Which They Occurred.

If You Smoke, When Did You Start?

If You Used To Smoke, When Did You Quit?

How Stressful Is Your Life? (1 = Lowest, 10 = Highest)

How Do You Practice Stress Management?

Do You Participate In Regular Physical Activity?

If So, What Kind Of Activites & How Often?

How Do You View Your Weight?

What Do You Consider A Good Weight For Yourself?

What Is The Most That You've Ever Weighed?

List Your Top 3 Fitness Goals

I pledge that all the information which I have provided in this form is accurate, to the best of my knowledge, and that I have not willingly excluded any important medical information which could have any bearing on my ability to safely engage in exercise testing and exercise participation.

E-Signature

Date Signed

End Rezults Health Questionnaire

Free Body Scan

40 Data Points

Weight

Muscle Mass

Visceral Fat Mass

Calories Until Goal

Digital Business Card

End Rezults Booking Request

End Rezults Health Questionnaire

End Rezults Health Questionnaire

Free Body Scan

*40 Data Points*

Weight

Muscle Mass

Visceral Fat Mass

Calories Until Goal

Digital Business Card

End Rezults Booking Request

End Rezults Health Questionnaire

40 Data Points