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Questionnaire
Occupational, Recreation, Medical
Are you currently employed? If Yes, what is your current occupation?
*
Yes
No
Does your occupation require extended periods of sitting? How many hours?
*
Yes
No
Choose an option
Does your occupation require extended periods of repetitive movements? (If yes, please explain.)
*
Yes
No
Does your occupation require you to wear shoes with a heel (dress shoes)?
*
Yes
No
Does your occupation cause you anxiety (mental stress)?
*
Yes
No
Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.
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Yes
No
Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.)
*
Yes
No
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.)
*
Yes
No
Have you ever had any surgeries? (If yes, please explain.)
*
Yes
No
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.)
*
Yes
No
Are you currently taking any medication? (If yes, please list.)
*
Yes
No
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