Questionnaire


BODY MASTER
Fitness Studio

QUESTIONNAIRE

Name:
Date:
Address:
Home Phone:
Cell:
Work Phone:
Personal Email:
Work Email:

Emergency Contacts

First Person:
Telephone Number:
Second Person:
Telephone Number:

Physician

Name:
Telephone Number:
Address:
Birth Date :
Age:
Gender:

HEALTH & FITNESS HISTORY

Current workout experience:
Previous workout experience:
Current sporting activities:
Previous sporting activities:
Current injuries:
Previous injuries:
Are you currently taking any medications?
Last time you had a physical examination?
Last time you saw your physician?
Was exercise recommended by physician?
Has your physician put any limitations on your exercise?

Do you now, or have you had in the past:

Comments:

Item #:
Comment:

Do you have a family history of:

Comments:

Item #:
Comment:
Do you have any other health considerations that have not been discussed in this questionnaire?
If yes, please explain:

I understand that any evaluation or exercise program has an associated risk. The risk can vary from minor strains and sprains to major injuries to sudden death. I have provided accurate and true information on this questionnaire and have supplied any possible problems or limitation not listed on this questionnaire. I assume the risk for my health and my program.

Signature of Client:
Date: