Thomas Long’s Health screening test.

HEALTH SCREENING TESTPLEASE COMPLETEScale 1-10. 1 meaning none 10 meaning allot

NAME:

DOB:

HEIGHT:

WEIGHT:

Have you ever been diagnosed with any heart problems? Do you have any breathing problems? (Asthma for example) If so how serious is this. Have you ever had High blood pressure at a resting heart rate? How active are you currently? (1-10)Would you describe yourself as healthy?Do you eat a balanced diet? Have you always been physically active?Do you play a sport?