Conca Sport and Fitness Health Questionnaire

In order for us to better help you, please take a few minutes to fill out this personal health questionnaire. Your information is kept completely confidential. You can expect a call or email follow up from us within 24 hrs to set up your complimentary CSF Fitness Consultation.

Conca Sport and Fitness is currently accepting a limited clientele to workout in our private training studio. All sessions are by appointment only and clients are selected through our online questionnaire application as well as personal interviews

* Required

Title DR MISS MR MRS MS

First Name *

Last Name *

Email Address *

Date of Birth *

Do you have a family history of heart disease: -- Please select -- Yes No

Please indicate if you are suffering from any heart condition such as heart disease or high blood pressure:

Do you suffer from hypoglycemia anemia or high cholesterol:

Have you had surgery and if so indicate the procedure and if it required physical therapy:

Do you suffer from joint pain such as arthritis or a musculoskeletal disorder:

Are you diabetic or suffer from hypoclycemia:

Are you pre or post natal: -- Please select -- pre post

Do you suffer from a pulmonary disease or shortness of breath:

Have you or do you suffer from any other kind of joint or muscle pain:

Do you suffer from food allergies or a GI disorder:

Is your physician prescribing medication for high blood pressure or cholesterol:

Has your physician told you that you have a bone or joint condition that will worsen with exercise:

Do you know any reason why you should not exercise:

Are you medically cleared to exercise: -- Please select -- Yes No

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