Fitness Center Health Risk Appraisal
Personal Information
Full Name
Date of Birth
Gender
Email
Phone Number
Emergency Contact
Contact Name
Relationship
Contact Phone
Medical History
Do you have, or have you had, any of the following? (Check all that apply)
Heart Disease
High Blood Pressure
Diabetes
Asthma
Arthritis
Other
If yes to any, please provide details
Lifestyle
How often do you exercise per week?
0 times
1-2 times
3-4 times
5+ times
Do you smoke?
No
Yes
Do you drink alcohol?
No
Yes
Current Symptoms
Are you currently experiencing any of the following? (Check all that apply)
Chest Pain
Shortness of Breath
Dizziness
Joint Pain
None
Fitness Goals
Please describe your fitness goals
Additional Notes
Anything else we should know?