Health History Questionnaire | Sparks Systems

Name*

First Middle Last

Email*

Date of Test*

MM

DD

YYYY

Age*

Team/Group affiliation

Type of test*

Gender*

Date of Birth*

MM

DD

YYYY

Current Weight*

Goal Weight

Height*

Street Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Number*

Current Medications?*

What time do you typically stop eating each day?*

What are your goals with metabolic testing?*

Any past or current medical conditions we should know about?*

How did you hear about testing with us?*

Do you follow any type of restrictive diets?*

vegan, vegetarian, gluten free, etc

Do you have any history of an eating disorder?*

Anything else we need to know about you?*

List your health insurance provider*

How many hours do you exercise per week?*

Emergency Contact Name*

Emergency Contact Phone*