Pinnacle Fitness Center Health History Questionnaire
First Name
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Last Name
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Phone
*
Email
*
Address
City
State
Postal code
To change date range click on the year and month and select the corresponding date.
Date of birth
Emergency Contact
*
Emergency Contact Phone
*
Contact Relationship
*
Have you had or presently have any of the following conditions? (Check all that apply)
Present / Past History
Asthma
Diabetes
High Cholesterol
Lung Disease
Stroke
Heart Disease
High Blood Pressure
Low Blood Pressure
Thyroid
Headaches
Seizures
PCOS
Recent Operation
Neck Pain
Chest Pain
Shoulder Pain
Elbow Pain
Wrist Pain
Back Pain
Hip Pain
Knee Pain
Foot Pain
Use this area to explain your checked present / past history if necessary.
Have you had or presently have any of the following conditions? (Check all that apply)
Digestive Health History
Abdominal Cramps / Pain
Acid Reflux
Allergiers
Appendicitis
Cancer
Celiac Disease
Crohns Disease
Constipation
Diarrhea
Gall Stones
Gas
Inflammation
Liver Disease
Kidney Disease
Polyps
Thyroid Disease
Ulcers
Irritable Bowel Syndrome
Use this area to explain your checked digestive history if necessary.
Active History
What is your present occupation?
*
What's motivating you to make a change in your health now?
*
What are you looking for in a fitness program?
Do you have injuries (bone, muscle, ligament, tendons, rods or pins) that may interfere with exercising?
List the medications you are presently taking.
LAST & Most IMPORTANTLY. What's motivating you? Why is this important to you? (List the top 3-5 reasons WHY you want to get started.)
*
Females Only
Do you take birth control? (If you answer yes, have you had problems with weight loss or metabolic issues?)
Do you have menstrual cycle irregularities? (Please explain if answering yes.)
Are you currently pregnant?
Yes
No
Liability Waiver
“I have enrolled in a program of strenuous physical activity including but not limited to weight training and the use of any aerobic conditioning equipment offered by Pinnacle Fitness Center, LLC. I affirm that I am in good physical condition and I do not suffer from any disability that would prevent or limit my participation in this exercise program. I release Pinnacle Fitness Center to use pictures taken of me exercising. I fully understand that I may injure myself as a result of my participation in the Pinnacle Fitness Center exercise program and I hereby release Pinnacle Fitness Center, LLC, its employees, contractors, and owners from any liability now or in the future, including but not limited to heart attacks, strokes, muscle strains, sprains, shin splints, broken bones, heat prostration, knee/ lower back/ foot injuries, and any other illness, soreness, injury, or sudden death however caused during or after my participation in this exercise program.”
By approving this agreement you signify that you understand and support the terms stated above.
Liability Signature
*
Clear