Exercise Medical History Questionnaire
Please complete this form to help us understand your health status and ensure safe participation in exercise activities.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently have, or have you ever had, any of the following conditions? (Select all that apply)
*
Heart disease
High blood pressure
Diabetes
Asthma or other respiratory issues
Joint or bone problems
Recent surgery
None of the above
Other
Please list any current medications you are taking
Do you have any allergies (e.g., medications, foods, environmental)?
Have you experienced any injuries or surgeries related to physical activity? If yes, please describe.
How would you describe your current exercise habits?
*
I do not exercise currently
Light activity (e.g., walking, yoga) 1-2 times per week
Moderate activity (e.g., jogging, cycling) 3-4 times per week
Vigorous activity (e.g., intense sports, weightlifting) 5+ times per week
Other
Are there any physical activities you are unable to perform or that make you uncomfortable? If yes, please specify.
Do you have any specific goals or concerns regarding your exercise program?
Submit
Should be Empty: