Fitness and Lifestyle Questionnaire | |||||||||||||
Name (Last, First, MI.): | | ¨ M ¨ F | DOB Age | | |||||||||
Marital status: | ¨ Single ¨ Partnered ¨ Married ¨ Separated ¨ Divorced ¨ Widowed | ||||||||||||
Height | | Weight | Weight at age 18 | ||||||||||
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PERSONAL HEALTH HISTORY | |||||||||||||
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How many hours of sleep do you typically get a night? | | ||||||||||||
Health Screening values | ¨ Typical BP | | ¨ Resting Heart Rate | | |||||||||
¨ LDL | | ¨ Maximum Heart Rate (exercise Heart Rate) | | ||||||||||
¨ HDL | | ¨ Fasting Glucose | | ||||||||||
List any medical problems or diagnosis | |||||||||||||
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Surgeries | |||||||||||||
Year | Reason | Activity level after therapy | |||||||||||
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Other hospitalizations | |||||||||||||
Year | Reason | Activity Level after recovery | |||||||||||
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List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers | |||||||||||
Name the Drug | Strength | Frequency Taken | |||||||||
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Allergies to medications | |||||||||||
Name the Drug | Reaction You Had | ||||||||||
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HEALTH HABITS AND PERSONAL SAFETY | |||||||||||
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All questions contained in this questionnaire are optional and will be kept strictly confidential. | |||||||||||
Exercise | ¨ Sedentary (No exercise) | ||||||||||
¨ Mild exercise (i.e., climb stairs, walk 3 blocks, golf) | |||||||||||
¨ Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.) | |||||||||||
¨ Regular vigorous exercise (i.e., work or recreation 4x/week for 30 minutes) | |||||||||||
Diet | Are you dieting? | ¨ | Yes | ¨ | No | ||||||
If yes, are you on a physician prescribed medical diet? | ¨ | Yes | ¨ | No | |||||||
# of meals you eat in an average day? | |||||||||||
Rank salt intake | ¨ Hi | ¨ Med | ¨ Low | ||||||||
Rank fat intake | ¨ Hi | ¨ Med | ¨ Low | ||||||||
Caffeine | ¨ None | ¨ Coffee | ¨ Tea | ¨ Cola | |||||||
# of cups/cans per day? | |||||||||||
Alcohol | Do you drink alcohol? | ¨ | Yes | ¨ | No | ||||||
How many drinks per week? | |||||||||||
Tobacco | Do you use tobacco? | ¨ | Yes | ¨ | No | ||||||
¨ Cigarettes – pks./day | ¨ Chew - #/day | ¨ Pipe - #/day | ¨ Cigars - #/day | ||||||||
¨ # of years | ¨ Or year quit | ||||||||||
Personal Safety | Do you live alone? | ¨ | Yes | ¨ | No | ||||||
Do you have frequent falls? | ¨ | Yes | ¨ | No | |||||||
Do you have vision or hearing loss? | ¨ | Yes | ¨ | No | |||||||
| Please list additional concerns | | | | | ||||||
FAMILY HEALTH HISTORY |
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| Age | Significant Health Problems | | | | |
Father | | | ||||
Mother | | | ||||
Exercise adherence factors | ||||
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Is stress a major problem for you? | ¨ | Yes | ¨ | No |
Do you feel depressed? | ¨ | Yes | ¨ | No |
Do you get easily bored with your workout routine? | ¨ | Yes | ¨ | No |
Do you have problems with eating or your appetite? | ¨ | Yes | ¨ | No |
Do you have an exercise buddy? | ¨ | Yes | ¨ | No |
Do you stop and start exercise programs frequently? | ¨ | Yes | ¨ | No |
Do you feel that you need a personal trainer? | ¨ | Yes | ¨ | No |
Do you often feel overly tired after exercise? | ¨ | Yes | ¨ | No |
Are you sore for days after exercise? | ¨ | Yes | ¨ | No |
Activity Overview | ||||
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What is your favorite fitness activity? | ||||
Do you participate in sports of any kind? If so, what type? | ||||
How often? | ||||
Goals | ||||
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Do you want to improve health habits? | ¨ | Yes | ¨ | No |
Do you want to learn more about exercise? | ¨ | Yes | ¨ | No |
Would you want to learn more about nutrition? | ¨ | Yes | ¨ | No |
Do you want to have better weight management? | ¨ | Yes | ¨ | No |
Do you want to have better fitness? | ¨ | Yes | ¨ | No |
Do you desire to have increased upper body strength? | ¨ | Yes | ¨ | No |
Do you desire to have increased lower body strength? | ¨ | Yes | ¨ | No |
Would you like to improve your flexibility? | ¨ | Yes | ¨ | No |
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Would you like to have better balance? | ¨ | Yes | ¨ | No |
Would you like to have more energy? ¨ Yes ¨ No | ||||
Would you like to improve your posture? | ¨ | Yes | ¨ | No |
Are you training for a special event? | ¨ | Yes | ¨ | No |
Please add additional goals | | | | |
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Please add motivating factors for you | | | | |
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