Health History Form Ignite Fitness Experience

Health History Form

Name

Address

Birth Date

Cell Phone

Email

Are you under the care of a physician or a healthcare professional of any type?

Yes

No

Are you currently taking any medication?

Yes

NO

Do you have high blood pressure?

Yes

No

Do you know of any reason why you should not engage in physical activity?

What is your current occupation?

Does your occupation require extended periods of sitting?

How many hours of sleep do you average per night?

How would you rate your energy level?

Fair

Good

Great

How would you rate your daily stress level?

Fair

Good

Great

Please provide in the box any further information you may feel that we need to know.

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Phoenix, Arizona

vicki.hogland@gmail.com

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We will get back to you as soon as possible

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