Fitness Health Assessment Form Page 2
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4FITNESS HEALTH ASSESSMENT FORM
Occupational Questions
1. What is your current occupation?
_______________________________________________________________________________
2. Does your occupation require extended periods of sitting?
Yes
No
3. Do you sit for more than 8 hours a day?
Yes
No
4. Do you use a computer or sit a desk more than 8 hours a day?
Yes
No
5. Does your occupation require extended periods of repetitive movements?
Yes
No
If yes, please explain___________________________________________________________
6. Does your occupation require you to wear shoes with a heel (dress shoes)?
Yes
No
7. Does your occupation cause you anxiety or mental stress?
Yes
No
Medical Questions
1. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?
Yes___________________________________________________
No
2. Have you ever had any surgeries?
Yes________________________________________________________
No
3. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary
artery disease, hypertension (high blood pressure), high cholesterol or diabetes?
Yes_______________________________________________________
No
4. Are you currently taking any prescription or over the counter medication(s)?
Yes_______________________________________________________
No
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Parent category: Medical