MRMC Wellness Lifestyle Questionnaire
1. Name
2. Email
3. Mobile Phone Number
4. Address
5. Gender
Mark only one oval.
Male
Female
6. Height
7. Current Weight
8. Date of Birth
Example: December 15, 2012
9. Who referred you to the wellness
program?
10. Has your doctor ever told you that you have heart trouble?
Mark only one oval.
Yes
No
11. Do you currently have diabetes?
Mark only one oval.
Yes
No
12. Have you had pains in your heart or chest?
Mark only one oval.
Yes
No
13. Do you at times feel faint or have spells of severe dizziness?
Mark only one oval.
Yes
No
14. Do you have asthma, emphysema or bronchitis?
Mark only one oval.
Yes
No
15. Do you currently have thyroid problems?
Mark only one oval.
Yes
No
16. Have you had any of the following: shortness of breath especially upon exertion; heart
palpitations; leg cramps during walking; or persistent swelling around the ankles?
Mark only one oval.
Yes
No
17. Has a doctor ever told you about bone or joint problems such as arthritis that has
been aggravated by exercise or might be made worse with exercise?
Mark only one oval.
Yes
No
18. Are you pregnant?
Mark only one oval.
Yes
No
19. Has a doctor ever told you that your blood pressure was too high?
Mark only one oval.
Yes
No
20. Have your parents or siblings suffered from heart disease before the age of 55?
Mark only one oval.
Yes
No
21. Are you currently a cigarette smoker or have you smoked within the last 6 months?
Mark only one oval.
Yes
No
22. Has your doctor told you that your cholesterol level is too high?
Mark only one oval.
Yes
No
23. Has either of your parents or any siblings experienced any of the following
conditions?
Check all that apply.
Heart Attack
High Blood Pressure
Heart Operation
Congenital Heart Disease
Diabetes
24. Most Recent Blood Pressure
25. Resting Heart Rate
26. Depression Scale ­ where do you rate yourself?
Mark only one oval.
1
I typically do not feel
sad
2
3
4
5
I feel sad nearly all the
time
27. Do you have any specific current or former injuries, limiting conditions, previous
surgeries or chronic/regular pain that may affect your ability to exercise?
28. Please list any medications you currently use which might affect your heart rate,
blood pressure or affect your ability to exercise.
29. What do you want to achieve with wellness coaching and/or personal training? (your
goals & fitness interests)
30. Are you currently exercising on a regular basis? If so, how many times per week? Is it
strength training, cardio or something else?
31. What type of exercise/activity do you enjoy?
32. Food Allergies?
33. Do you often feel stressed?
34. How many hours of sleep do you get per
night?
35. What is your occupational life like?
36. How do you spend the majority of your day? Sitting, standing, etc.
37. Do you have any issues or considerations of which you want to inform your wellness
coach or personal trainer?
38. Do you have support from family or friends for your goals and desires?
39. What has contributed to your fitness level becoming what it is today?
40. Please list any nutrition supplements you consume regularly.
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