Corporate Wellness Fitness Screening Form
Personal Details
Full Name
Date of Birth
Department / Team
Email Address
Phone Number
Medical History
Heart Condition
High Blood Pressure
Diabetes
Asthma or Breathing Issues
Recent Surgery or Injury
Other
If Other, please specify
Lifestyle & Activity
How would you rate your current activity level?
Sedentary
Lightly Active
Moderately Active
Very Active
What types of exercise do you currently participate in?
How often do you exercise per week?
Fitness Goals
Emergency Contact
Name
Phone Number
Relationship