Health History Form

Health History

* Indicates required field

Name *

First

Last

Email *

Phone Number *

How did you hear about us? *

Please answer "yes" or "no" to the following questions.

Has your doctor ever said you have a heart condition and that you should only do physical activity prescribed by a doctor? *

Yes No

Have you been restricted to physical activity prescribed by your doctor? *

Yes No

Do you feel pain in your chest when you do physical activity? *

Yes No

In the past month, have you had pain in your chest when you are not doing physical activity? *

Yes No

Do you lose your balance because of dizziness or do you lose consciousness? *

Yes No

Is your doctor currently prescribing drugs for your blood pressure or heart condition? *

Yes No

Do you have bone or joint problems that could be made worst by a change in physical activity? *

Yes No

Any previous injury still affecting you? *

Yes No

Any chronic illness or condition? *

Yes No

How would you rate your current fitness level? *

Beginner Intermediate Advanced

Are you pregnant? *

Yes No

Any pregnancies within the last 6 months? *

Yes No

Is there any other reason why you should not participate in physical activity? *

Yes No

Submit

Nimble Monkey Fitness
3930 Utah St. Suite C1
San Diego, Ca 92104
(619) 786-4026