HEALTH & FITNESS QUESTIONNAIRE Name * First Name Last Name Email * Phone * Country (###) ### #### Date of Birth * 01/01/1981 Zip Code * Height * Weight * Medical History & Food Sensitivity * Please check all that apply Heart condition and/or recommended only medically-supervised activity Chest pain brought on by physical activity Lose consciousness or fall over from dizziness Bone or joint problems that may be aggravated by physical activity Take medication for blood pressure or heart disease Food Allergy (ex: gluten or dairy sensitivity, shellfish etc.) None Thank you!
