Nasm Physical Activity Readiness Questionnaire & General & Medical Questionnaire Template Page 2
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2GENERAL & MEDICAL QUESTIONNAIRE
Occupational Questions
Yes
No
1
What is your current occupation
?
______________________________________________________________
2
Does your occupation require extended periods of sitting
?
3
Does your occupation require extended periods of repetitive movements
? (If yes,
please explain.)
_________________________________________________________________
4
Does your occupation require you to wear shoes with a heel (dress shoes)
?
5
Does your occupation cause you anxiety (mental stress)
?
Recreational Questions
Yes
No
Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please
6
explain.)
_________________________________________________________________
_________________________________________________________________
7
Do you have any hobbies (reading, gardening, working on cars, exploring the Internet,
etc.)? (If yes, please explain.)
_________________________________________________________________
_________________________________________________________________
Medical Questions
Yes
No
8
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)
?
(If yes, please explain.)
_________________________________________________________________
_________________________________________________________________
9
Have you ever had any surgeries
? (If yes, please explain.)
_________________________________________________________________
_________________________________________________________________
10
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
? (If yes, please explain.)
________________________________________________________________
________________________________________________________________
11
Are you currently taking any medication
? (If yes, please list.)
________________________________________________________________
________________________________________________________________
________________________________________________________________
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