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Medical History:
Do you have any chronic medical conditions? (e.g. diabetes, hypertension, asthma etc.)
Have you had any surgeries in the past?
Are you currently taking any medications or supplements?
Do you have any known allergies? (e.g. medications, foods, environmental)
Do you have a family history of any significant medical conditions? (e.g. heart disease, cancer, diabetes etc.)
Lifestyle and Habits:
How often do you exercise?
List the types of exercise and the duration:
How would you describe you diet?
Do you follow any specific diet? (e.g. paleolithic, keto, vegetarian, vegan, low-carb)
Do you smoke?
Do you consume alcohol?
If regularly, how many drinks per week?
How many hours of sleep do you get on average per night?
How would you rate your stress level?
General Health:
Do you experience any of the following regularly? (Check all that apply.)
When was your last medical check-up?
Have you received any vaccinations recently? ( e.g. Flu shot, Covid 19)
Fitness Goals:
Check all the items below that are important for you to address.
Health Goals:
Thank you for completing this preliminary "healthspan" questionnaire. The information gathered is strictly confidential and will not be shared. If you have any questions please forward them to the email address.
Now let's get you on your way to improving your HEALTHSPAN!!!!
AdonnasFitnessRoom@gmail.com