Health Questionnaire Name * First Name Last Name Email * Phone * (###) ### #### Date * MM DD YYYY Date of Birth * Primary Care Physician Physician Phone Number (###) ### #### Does your doctor know you are going to participate in this program: * Yes No Do you wear a Medic-Alert Tag or any other marker of a medical problem? * Yes No If yes, please describe: Do you have allergic or anaphylactic reactions to foods, drugs, insect bites or stings? * Yes No If yes, please describe, and let us know if you carry an Epi pen or other fast-acting medication: If you walked on the level for a mile at an average pace would you get out of breath, have pains in the chest, develop muscle fatigue or have pains in your legs? * Yes No Describe your degree of fitness in your own words: Do you have any other health-related disease, condition, or concern that program guides should be aware of? * Yes No If yes, please describe: Thank you!
