Health Questionnaire
Physician's contact Info
Name:
E-mail:
Phone Number:
Use the scale to rate levels for each question.
Answer the no if the condition doesn't apply to you, otherwise briefly describe how each condition affects your life, in the text box if provided.
Difficulty with physical exercise
Yes,
No
Advice from physician not to Cycle
Yes
No
Do you now have, or have you had in the past?
Recent surgery (last 12 months)
Yes,
No
Pregnancy(now or within last 3 months)
Yes
No
Do you dislike answering health related questions for recreational activities (ex. personal training, snowboarding, cycling)?
Yes
No
Muscle, joint, or back disorder, or any previous injury?
Check all that apply, then describe below:
Describe any ways you think your previous injuries may affect your your rides.
