Health & Lifestyle Questionnaire

Activity History/Goal

Tell us a little about your current exercise or activity.

Health Screening - History

Please provide some general information about your overall health.

Has your doctor told you that you have blockage to the circulation in your legs (peripheral arterial disease)?

Yes

Health Screening - Signs and Symptoms

Please provide answers to these questions based on the last 12 months.

Do you have a joint, back, or neck injury that significantly limits your ability to be physically active?

Yes

Health Information Acknowledgement

I have answered all questions truthfully and to the best of my knowledge. I have not knowingly withheld any information regarding my health. I understand that it is my responsibility to update the Reh-Fit Centre staff about any changes in health status that could affect my ability to safely participate at the Reh-Fit Centre.

This acknowledges that all information provided is true and understanding of my responsibilities.