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Seniors Fitness Online Health Questionnaire
To enable appropriate modification of the program, please indicate if you have any of the following medical conditions and provide further detail as necessary:
Type 1 diabetes
Type 2 diabetes
Hypertension (high blood pressure)
Ischemic Heart disease
Spinal Stenosis / Spinal surgery
Chronis lower back pain
Gait and balance disorders
Dementia (please specifiy bellow)
Stable congestive heart failure
Patient on chronic corticosteroid therapy
Cerebral vascular accident
History of fracture
Further information / Other relevant medical conditions:
1. Do you have any injuries that may affect your ability to exercise? If so, please give detail.
2. Do you have or have you ever had any back pain? If so, please give detail.
3. How often do you have a drink containing alcohol?
4. Do you smoke or have you quit smoking in the last 12 months?
5. How often do you exercise and what do you do?
6. Do you ever feel any Shortness of breath or pain in your chest when exercising? If so, please give detail.
7. What do you hope to achieve from this program?
1. How satisfied are you with your perceived level of physical fitness? Very Dissatisfied ---1---2---3---4---5---6---7---8---9---10--- Very Satisfied
2. How satisfied are you with your current level of exercises? Very Dissatisfied ---1---2---3---4---5---6---7---8---9---10--- Very Satisfied
I declare that I have understood this form, that all information detailed above is true to the best of my knowledge and I have informed Seniors Fitness of all existing health information. I will inform Seniors Fitness of any new or changes in my health conditions.
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