Custom Workout Questionnaire — Carson Laine Siler

Please complete and submit this form.

Name

First Name

Last Name

STATS/HEALTH HISTORY

Current weight:

Current age:

Height:

Current measurements:

(Please include bicep, chest, waist, hips, thigh)

Are you taking any daily medications? If yes, what are they for?

Do you have any significant medical history or current diagnoses? If yes, please detail below:

(e.g. chronic hypertension, PCOS, COPD, asthma, stroke, recent injuries, chronic pain)

Do you smoke?

Do you ever feel chest pain or dizziness when completing exercise?

Are you pregnant, planning to become pregnant, or postpartum?

(postpartum: given birth within last year)

Current profession:

Average amount of sleep per night:

GOALS