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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