Services Customer health questionnaire Health questionnaire for Peal’s Performance and Wellness Academy Step 1 of 4 25% NameDate of birthGenderEmail Phone numberEmergency contact nameEmergency contact phone number Please answer the following questions honestly and to the best of your ability. Your responses will help ensure your safety during ‘Strength and conditioning’ sessions. Do you currently have any injuries or physical limitations? If yes, please specify. Yes No Injuries/physical limitations detailsHave you undergone any surgeries in the past year? If yes, please provide details. Yes No Past surgeries detailsAre you currently taking any medications? If yes, please list them. Yes No Medication listHave you ever been diagnosed with any of the following conditions? Please check all that apply: Heart disease High blood pressure Diabetes Asthma Epilepsy Arthritis Osteoporosis Chronic pain Other Please specify other conditions Do you experience chest pain or discomfort during physical activity? Yes No More details about the pain/discomfortHave you ever fainted or experienced dizziness during or after exercise? Yes No More details about the dizzinessAre you pregnant or trying to become pregnant? Yes No More details about your pregnancyDo you have a history of any of the following conditions? Please check all that apply: Stroke Heart attack Joint dislocations Sprains or strains Concussions or head injuries Other Please specify other conditions Do you currently smoke? Yes No How many cigarettes do you smoke per day?On average, how many hours of sleep do you get per night?How would you rate your current level of physical activity? Please select one: Sedentary (little to no physical activity) Lightly active (regular light exercise or physical activity 1-3 days per week) Moderately active (regular moderate exercise or physical activity 3-5 days per week) Very active (regular intense exercise or physical activity 6-7 days per week) Is there anything else you think we should know about your health or medical history?By signing below, I acknowledge that the information provided is accurate and complete to the best of my knowledge. I understand that it is my responsibility to inform the instructor of any changes to my health status.SignatureDate MM slash DD slash YYYY Thank you for taking the time to complete this questionnaire. Your safety and well-being are our top priorities. If you have any questions or concerns, please don't hesitate to discuss them with your instructor. EmailThis field is for validation purposes and should be left unchanged. Get the additional discounts for booking:Rehab, Hot & Cold, Strength & Conditioning sessions! Get in touch If you have any questions or concerns regarding our therapy sessions, or if you want to make an appointment, please reach out. Get in touch
