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Health Questionnaire

Gender
Male
Female
Other
Prefer not to answer
Are you currently under the care of a doctor?
Yes
No
Have you performed planned, structured physical activity for at least 30 minutes, at moderate intensity, on at least 3 days per week, for at least the last 3 months?
Yes
No
Have you ever had a heart condition or coronary artery disease?
Yes
No
Do you have a family history of heart conditions or coronary artery disease?:
Yes
No
Do you have a history of high blood pressure (above 140/90)?
Yes
No
Do you have diabetes?
Yes, Type 1 Diabetes
Yes, Type 2 Diabetes
No
Do you worry about your weight?
Yes
No
Are you trying to or has anyone recommended that you gain or lose weight?
Yes
No
Are you currently on a special diet?
Yes
No
Are you currently under the care of a physical therapist?
Yes
No
Do you have trouble sleeping?
Yes
No
Have you ever participated in a diet and/or nutrition program?
Yes
No
Do you currently take laxatives and/or diuretics?
Yes
No
Do you currently use a fitness tracker?
Yes
No

Please complete the form below prior to your first appointment. If you need assistance, please let us know. 

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