Health History


Profile Picture (Internal Use Only)
First Name
Last Name
Email
Phone
Height (in feet) and Weight (in pounds)
Do you have any food or insect allergies? YesNo
Our food plan is gluten, wheat, dairy and land-animal free, with minimal soy, including smoothies for breakfast and dinner. Do you require any special diet (extra charge)? YesNo
If you are taking medications right now, will any of them affect your weight loss results? YesNo
Do you have visual or hearing impairments that may affect your programming?YesNo
Are you currently being treated for depression?YesNo
Do you have any medical illness, injury or physical restriction that may influence your participation? YesNo
Do you have any injuries that may influence your participation? YesNo
Have you suffered any of the below in the past 3 years?
Heart disease    Heart Attack   Diabetes    Asthma

Hypertension    High Cholesterol     Angina

Do you smoke cigarettes, vaporizers, tobacco or any other drug at the time of signing this waiver? YesNo
If you still smoke, do you understand and accept our zero tolerance policy to smoking, consuming alcoholic beverages, and consuming any food that is not provided by us during both scheduled and unscheduled hours? YesNo
As per our terms and conditions, we are unable to accept your registration. Please contact our office for cancellation of your program, or agree to this question.
If you are still a smoker, do you understand that you are responsible for selecting and bringing with you to Whistler Fitness Vacations all necessary tools to assist in quitting? Not ApplicableYesNo
As per our terms and conditions, we are unable to accept your registration. Please contact our office for cancellation of your program, or agree to this question.
How many alcoholic drinks do you drink on an average week?
Have you, or ever had an anorexia or bulimia for longer than 3 months?YesNo
How many hours per night do you sleep on average?
On a scale of 1-­10, how stressful is your life?
Do you know how to ride a bike? (Step-through cruiser bikes are used on concrete path) YesNo
Do you know basic swimming skills ­ e.g. how to breathe underwater? YesNo
Do you agree with our social guidelines:

  • Cell phones off during scheduled hours, except for photos
  • No headphones during scheduled hours
  • No gum during scheduled hours
  • Have a working alarm clock/watch/cell phone so you’re not late
  • Stay 10ft behind and in-front of other guests when hiking/running
  • No self-shaming or negative talk about your body size or fitness level

YesNo

Our weekly food plan Ingredients:

We are confident that you will love The Planet Friendly Diet, however if you have allergies or strong dislike for any of the below ingredients, check the corresponding box and advise us as to what you’d like to substitute it with. If you don’t need to change anything (yay!) don’t check anything.

Week one

BananaLemonMushroomRed Bell PepperYellow Bell PepperJalapeno PepperZucchiniCilantroIceberg LettuceGreen BeansCarrotBroccoliTomatoRed OnionGingerGarlicSpinachSnap PeasMixed BerriesCoconut TilapiaWhite FishTunaSalmonTofuSoy CheeseYogurtHummus

Week Two

AsparagusCeleryBean SpoutsPotatoesRed CabbageAvocado

Week Three

MangoZucchiniPineappleWhite OnionCucumber

Tell us a little about yourself ­ what you hope to achieve from our program, why you chose us, how we can best help you enjoy your stay, if there’s anything you need to ensure your time with us is perfect.

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