3. Nutrition & Medical Screening Questionnaire
1.
First Name
2.
Last Name
3.
Have you ever had a nutrition assessment done before?
Yes
No
If yes, please explain.
4.
Have you ever had any injuries or chronic pain?
Yes
No
If yes, please explain.
5.
Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes?
Yes
No
If Yes, please explain.
6.
Have you ever had any surgeries?
Yes
No
If Yes, please explain.
7.
How often do you eat out?
Almost Every day
Less Than Once a Week
Less Than Once a Month
A Few Times a Week
Other (please specify)
8.
Are you currently taking any medication?
Yes
No
If Yes, please explain.
9.
Do you know of any other reason why you should not engage in physical activity?
Yes
No
If yes, please explain.
10.
Please list any other information your trainer may find useful in preparing a workout routine for you: