Health, Wellness and Lifestyle Questionnaire
Name:______________________________
Phone#_____________________________
8.
__________________________________________
9.
Date of Birth: ____________
What types of things make you feel stressed?
How do you deal with your stress?
Sex: M / F
__________________________________________
Person to contact in case of emergency:
Name: ___________________________
Phone#___________________________
The following information is required and
together with the Functional Movement
Screen will assess your physical fitness level
to establish an customized exercise program.
Your health questionnaire and test results are
confidential and will not be released to anyone
other than yourself.
1.
In the past year, how often have you been
engaged in physical activity?
___ (4- 5 times/ week)
___ (2- 3 times/ week)
___ (1- 2 times/ week)
___ (None)
2.
What type of physical activity do you consider
fun?
_______________________________________
3.
What are your personal barriers to exercise?
__________________________________________
4.
What physical activity have you been successful
with in the past?
__________________________________________
5.
What is your present occupation?
__________________________________________
6.
7.
Does your occupation require much activity ( i.e.
walking, carrying things etc.)
Yes___ No___
What are your leisure activities?
__________________________________________
10. How many meals and/or snacks do you have per
day?
__________________________________________
11. Do you feel that you eat healthy most of the
time?
Yes___ No___
12. Specifically describe what you would like to
accomplish through your fitness program during
the next:
1 month
__________________________________
4 months
__________________________________
1 year
__________________________________
13. Do you have any negative feelings toward, or
have you had any bad experiences with physical
activity programs?
Yes___ No___
If yes, explain.
___________________________________________
14. Do you start an exercise program but then find
yourself unable to stick with them?
Yes___ No___
15. How much are you willing to devote to an
exercise program?
______min/day ______ days/week
16. Are you currently involved in regular exercise?
Yes___ No___
Health, Wellness and Lifestyle Questionnaire
17. Can you exercise during the work day?
Yes___ No___
18. Would an exercise program interfere with your
job?
Yes___ No___
19. Would it benefit your job?
Yes___ No___
20. What type of exercises interest you?
___ Walking
___ Jogging
___ Swimming
___ Cycling
___ Strength training
___ Rowing
___ Tennis
___ Golf
___ Stretching
___ Other
21. What do you want exercise to do for you?
____________________________________
22. Use the following scale to rate each goal
separately:
Very Important
1
2 3 4
5
6
7
a. Improve cardiovascular fitness
b. Body-fat weight loss
c. Reshape/tone my body
d. Sport specific
e. Ability to cope with stress
f. Improve flexibility
g. Increase strength
h. Increase energy level
i. Feel better
j. Improve posture
k. Enjoyment
l. Other
Not important
8
9 10
___
___
___
___
___
___
___
___
___
___
___
___
23. How much would you like to change your
current weight?
(+) _____ lbs. (-) _____ lbs.
24. Anything else you would like your trainer to
know?
______________________________________