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9170 Charles de laTour, Montreal, H4N 1M2
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Health and lifestyle questionnaire
Gym
2025-01-15T21:54:03+00:00
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Tell us about yourself
First Name
Last Name
Email Address
Phone Number
Date of birth
Age
Age you feel
Height
Weight
% body fat
Goals
Time frame
How many times a week train
Questionnaire
Do you smoke?
Yes
No
Do you drink?
Yes
No
Do you have any heart conditions?
Yes
No
Have you ever had a stroke or heart attack?
Yes
No
Do you ever feel faint or have dizzy spells?
Yes
No
Have you had surgery in the last year?
Yes
No
Do you have any muscle, bone or joint problem?
Yes
No
Are you taking any medications?
Yes
No
Are you taking any supplements?
Yes
No
Would you consider taking enhanced or regular supplements if needed?
Yes
No
Check any of the following that apply to you
Diabetes
High Cholesterol
High blood pressure
Heart Disease
Back Pain
Arthritis
Asthma
Thyroid
Have you injured or have pain in the following areas? Check any of the following that apply to you.
Neck
Shoulder
Lower Back
Upper Back
Hips
Elbows
Wrists
Knees
Other
My job stresses me out.
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10
I am in the best shape of my life.
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10
I am serious about achieving my goals.
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I would rate my current physical fitness.
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10
How many hours of sleep.
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How many days can you train.
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7
How many cups of water do you drink per day on average? (1 cup = 1 glass)
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9
10 or more
How many cups of cafeinated beverages do you drink per day? (coffee, tea)
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9
10 or more
I eat in response to stress.
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9
10
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