Health History - Purchase 21 day body detox diet for colon cleansing and healthy weight loss

Personal Information

Name:                           Today's Date:                 //

Address:                    Apt. # DOB:                 //

City:                               State:                 Zip Code:

Daytime Phone:                             Evening Phone:

Email Address:                                Age:                     Male    Female

Emergency Contact:                    Phone:

Dr. Name:                        Phone:

Occupation/Lifestyle

What is your current occupation?

Physical Activity Readiness Questionnaire (PAR-Q)


If you answered YES to any of the questions above, MBS Proactive Health and Wellness LLC requests written permission from your physician before you may participate in physical and aerobic fitness activities. If you choose not to get written permission, you acknowledge by indicating that MBS Proactive Health and Wellness LLC has asked you to visit your physician to obtain a medical release before beginning an exercise program. You have elected not to do so and assume the risk for any injuries arising from undertaking any and all exercise due to a known/unknown medical condition.	I agree to obtain written permission	I choose NOT to obtain written permission
If you answered NO to all questions above, you have provided to MBS Proactive Health and Wellness LLC, a general indication that you may participate in physical and aerobic fitness activities and/or fitness evaluation testing. The fact that you answered NO to the above questions, is no guarantee that you will have a normal response to exercise or that a fitness regimen will not cause you medical problems.	Agree	Disagree

Other/General
Additional comments:

	Yes	No

Does your occupation require extended periods of sitting?
Does your occupation require repetitive movements?
Does your occupation require you to wear shoes with a heel (dress shoes)?
Does your occupation cause you anxiety or stress?
Do you take part in any recreational activities (golf, tennis, skiing, etc.)? If yes, please list all recreational activities
Do you have any hobbies? If yes, please list all hobbies

	Yes	No
Has a doctor ever said that you have heart trouble or a heart condition? If yes, please explain any limitations in activities.
Has a doctor ever told you that you are diabetic? If yes, please explain any limitations in activities
Do you frequently have pains in your heart and chest? If yes, please explain any limitations in activities
Do you often feel faint or have spells of severe dizziness? If yes, please explain any limitations in activities
Has a doctor ever said that your blood pressure was too high? If yes, please explain any limitations in activities
Has a doctor ever told you that you have bone/joint problems or Arthritis? If yes, please explain any limitations in activities
Has a doctor ever told you that your cholesterol was too high? (Total >200mg/dl or LDL >130mg/dl or HDL <35mg/dl or Total to HDL ratio >5) If yes, please explain any limitations in activities
Do you smoke? If yes, please explain any limitations in activities

Is there any medical reason why you should not follow an activity program? If yes, please explain any limitations in activities.
Are you a (man over the age of 45 or woman over the age of 55) AND not accustomed to vigorous exercise? If yes, please explain any limitations in activities
Do you suffer from any problems of the neck, back or knees? If yes, please explain any limitations in activities
Do you suffer from any problems i.e. chronic pain, injury or numbness? If yes, please explain any limitations in activities
Are you currently taking any medications? If yes, please specify
Do you have any previous surgeries or injuries? If yes, please specify