Health and Wellness Questionnaire

June 11, 2011

All the information provided by you is strictly confidential

Name: ________________

Age: ___________________

Why according to you is healthy body important?

___________________________

What does health and wellness means to you?

___________________________

Have you been treated for any kind of heart disease in the past?

___________________________

Is there a chest pain whenever you are involved in a physical activity?

_____________________________

Are you under any medical supervision?

_______________________________

Is there any other activity that results in chest pain?

_______________________________

Have you ever fainted or felt nausea tic?

_____________________________________

Do you have high blood pressure problem?

_________________________________

Is it difficult for you to breathe whenever you exercise?

_________________________________________________

Are you aware of any medication that you are taking?

________________________________________

Are you currently pregnant?

____________________________________

Did you give birth to a child in last two months?

______________________________________

Did you have a surgery recently?

_______________________________

Do you have any physical disability or any condition that prevents you from exercising?

____________________________________

Do you have a high level of cholesterol?

________________________________

Download Health and Wellness Questionnaire in Word Format

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