3. Nutrition & Medical Screening Questionnaire Question Title * 1. First Name Question Title * 2. Last Name Question Title * 3. Have you ever had a nutrition assessment done before? Yes No If yes, please explain. Question Title * 4. Have you ever had any injuries or chronic pain? Yes No If yes, please explain. Question Title * 5. Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? Yes No If Yes, please explain. Question Title * 6. Have you ever had any surgeries? Yes No If Yes, please explain. Question Title * 7. How often do you eat out? Almost Every day Less Than Once a Week Less Than Once a Month A Few Times a Week Other (please specify) Question Title * 8. Are you currently taking any medication? Yes No If Yes, please explain. Question Title * 9. Do you know of any other reason why you should not engage in physical activity? Yes No If yes, please explain. Question Title * 10. Please list any other information your trainer may find useful in preparing a workout routine for you: Finished