THE BODY SHOP HEALTH & WELLNESS, LLC
HEALTH & MEDICAL QUESTIONNAIRE

Please fill out the following form
in order to participate in our activity.

OR DOWNLOAD and hand in to gym location.

Contact Info
Emergency Contact Info
Personal Physician
Present/Past History
Have you had or do you presently have any of the following? (Check if yes.)
Family History
(Check if yes.) In addition, please identify at what age the condition occurred.
Activity History
Have you ever worked with a personal trainer before?
Do you participate in a regular exercise program at this time?
Can you currently walk 4 miles briskly without fatigue?
Have you ever performed resistance training exercises in the past?
Do you have injuries (bone or muscle disabilities) that may interfere with exercising?
Do you smoke?

Thanks for submitting!