PERSONAL DATA
Name:
Address:
Phone # (H)_______________ (B)_______________
Date of Birth:_______________ Gender: Male/Female
Emergency Contact:____________________ Phone #:_______________
Family Doctor:____________________ Phone #:_______________
HEALTH & MEDICAL HISTORY
In general, how would you describe your current state of health?
_Very Good _Good _Average _Poor _Very Poor
LIFESTYLE QUESTIONNAIRE
LIFESTYLE HABITS
Occupation: Position:
How would you describe your overall stress level?
_Very High _High _No _Occasionally
Do You smoke? _Yes _No _Occasionally
HEALTHY EATING HABITS
Do you regularly eat three meals a day? Yes or No
Do you snack throughout the day between meals? Yes or No
Do you eat an energy filled breakfast? Yes or No
If yes, what are you food choices?
How many fruits and vegetables do you eat per day?
How many grains do you eat per day?
How many glasses of pure fresh water do you drink per day?
Do you drink coffee, tea,coke or hot chocolate? Yes or No
If yes, how many per day?
Do you drink alcohol? Yes or No
If yes, when and how many per week.
What would you describe as your areas of eating weakness?
¨ Fats
¨ Sugars
¨ Salts
¨ Big Macs/over eat
¨ Packaged/processed
¨ Eating out often
¨ Others
Notes:
Would you like more information on healthy eating? Yes or No
FITNESS AND YOUR GOALS
Over a typical seven-day period, how many times do you engage in physical activity that is sufficiently prolonged and intense to cause sweating and a rapid heart rate?
¨ At least three times
¨ Normally once or twice
¨ Rarely or never
When you engage in physical activity, do you have the impression that you:
¨ Make an intense effort
¨ Make a moderate effort
¨ Make a light effort
In a general fashion, would you say that your current physical fitness is:
¨ Very Good
¨ Good
¨ Average
¨ Poor
¨ Very Poor
Were you involved in physical activity in high school or university? Yes or No
Are there any sports that you play regularly that you would like to keep in shape for or improve your abilities? Yes or No
What are the sports?
What obstacles do you think may prevent you from exercising regularly?
What are your fitness goals?
_ Improve cardiovascular condition?
_ Develop muscular strength - Focus: shape or mass
_ Improve flexibilty
_ Reduce body fat
_ Strengthen abdominals to support the lower back
_ Posture support
_ Rehabilitate an injury - Focus:
_ Improve general health and fitness
_ Reduce the effects of stress
_ Increase your energy levels
_ Personal enjoyment - fun
_ Other
How much time are you willing to commit to an exercise program on a weekly basis?
_2x/wk _3x/wk _4x/wk _5x/wk
What time of day could you commit to a regular schedule?
_am _daytime _pm
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