Lifestyle and Health History Questionnaire

Name

First Last

Date

Age

Gender

Height

Weight

Physician Name

Physician Phone

Emergency Contact

Emergency Contact Phone

EXERCISE

What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)?

How many days per week do you get at least 60 minutes of moderate-intensity exercise?

Please enter a number less than or equal to 7.

On a scale of 0 to 10, how important are the following fitness goals to you?

Weight loss:

Please enter a number from 1 to 10.

Muscle gain:

Please enter a number from 1 to 10.

Sports performance:

Please enter a number from 1 to 10.

Health improvement:

Please enter a number from 1 to 10.

Anything else about exercise you want to discuss?

DIET

On a scale of 0 to 10, do you consider your overall diet to be healthy?

Please enter a number from 1 to 10.

On a scale of 0 to 10, how effectively are you able to control your temptations for junk food?

Please enter a number from 1 to 10.

Are you currently following any kind of diet? If so, what diet and for what reason(s)?

How would you rank your daily salt intake

How would you rank your daily sugar intake

How would you rank your daily fat intake

How many alcoholic drinks do you consume per week?

How many caffinated drinks do you consume per week?

LIFESTYLE

Do you feel like you get enough sleep and wake up feeling rested each day?

Yes

Do you smoke tobacco or use a vaporizer alternative?

Yes

On a scale of 0 to 10, how would you rate your average level of stress?

Please enter a number from 1 to 10.

What techniques do you currently use to manage your stress levels?

OCCUPATION

What is your occupation?

Does your occupation require extended periods of sitting? (If YES, please explain.)

Does your occupation require repetitive movements? (If YES, please explain.)

Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)?

RECREATION

Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.)

Do you have any additional hobbies (gardening, fishing, music, etc.)? (If YES, please explain.)

MEDICAL

Please list out any past musculoskeletal injuries

Please list out any past surgeries

If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity?

Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary disorders, hypertension, diabetes, or cancer)? (If YES, please explain.)

Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity?

Additional Notes

Phone

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