Starting Point #5: Physical Dimension of Wellness

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

PERSONAL HEALTH HISTORY

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

Surgeries

Year

Reason

Activity level after therapy

Other hospitalizations

Year

Reason

Activity Level after recovery

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers
Name the Drug			Strength			Frequency Taken
Allergies to medications
Name the Drug			Reaction You Had
HEALTH HABITS AND PERSONAL SAFETY
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
	Age	Significant Health Problems
Father
Mother

Exercise adherence factors
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
What is your favorite fitness activity?
Do you participate in sports of any kind? If so, what type?
How often?
Goals
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
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
Please add motivating factors for you