MEDICAL/LIFESTYLE QUESTIONNAIRE
*All information on this questionnaire is confidential
MEDICAL
General Information
Name: Leah Carney
Address: 31 East Wolfert Station Road Mickleton, NJ 08056
Telephone Number: 856-472-2036
Email: carney24@students.rowan.edu
Date of birth: 11/1/1989
Gender: Female
Emergency Contact: Denise LaFalce ( Mother )
Telephone Number: 856-462-8065
Family illnesses
Please circle if there is any history in your family of:
1. Diabetes
6. Allergy
2. High blood pressure
7. Alcoholism
3. Obesity
8. Stroke
4. Cancer
9. Other: Heart Disease
5. Asthma
Please explain:
My Aunts suffer from high blood pressure and high cholesterol due to being overweight.
My Nanny died from a stroke at the age of 79.
My Father, brother, cousin, and Uncle all have/had a form of cancer.
My cousin died from it at the age of 17.
Past History
1. Have you had any surgeries? Circle one.
Yes
No
If so, please explain: I have had arthroscopic knee surgery to repair a torn medial meniscus.
The surgery took place in April of 2006.
2. Females only:
Have you ever given birth? No.
Date of onset menstruation: January 2007
Is your menstruation cycle regular?
Yes
No
3. Have you ever broken any bones? Circle one.
Yes
No
Please explain___________________________________________________________
4. Have you ever suffered from any of the following?
Circle all that apply.
heart attack
heart operation
heart disease
high cholesterol
If yes, give details________________________________________________________
_______________________________________________________________________
Present Health
1. How would you describe your present health? Circle one.
Excellent
Good
Fair/Poor
If fair/poor please explain briefly__________________
2. How often do you exercise? Circle one.
Never
Rarely
Once a week
Several times a week
Daily
3. Do you take prescription drugs routinely? Circle one.
Yes
No
If yes, please specify: Birth Control
4. Do you smoke? Circle one.
Yes
No
5. What is your current height and weight?
Height: 5’8”
Weight: 160lbs
6. How many hours of sleep do you get each day?
6-8 hours
7. Do you suffer from any of the following? Circle all that apply.
asthma
heart disease
high blood pressure
frequent colds
low blood pressure
headaches
arthritis
migraines
diabetes
joint pain
shortness of breathe
high cholesterol
LIFESTYLE
Occupation; Please explain your position along with the physical and mental responsibilities
involved.
I am a waitress at two Restaurants. Being a waitress requires a quick pace, multitasking, and
good memory. It can sometimes be stressful, but I love it which makes it more fun. I am also
constantly moving and do not sit down even when at times I may work a ten hour shift.
How much time do you spend in a seated position? None
Do you consider yourself to be under a lot of stress? Mild Stress from the amount of things I do
at a time.
Have you ever had a personal trainer? If yes provide details.
Do you follow, or have you recently followed any specific dietary intake plan, and in general
how do you feel about your nutritional habits?
I do not have the best eating habits, however they are also not terrible. I have always wanted to
eat healthier so that I can learn better habits. I think it is important to practice what you preach
and as a Health and Physical Education teacher and potential Personal Trainer. My father was
recently diagnosed with prostate cancer, so we began to eat more healthy as a family, which was
the first step in making a change. Secondly, after making my goals for this project I realized it
was essential to incorporate nutrition changes into my plan so that I could be successful.
1. Summary of Medical/Health Status and Current Lifestyle related to Exercise and
Nutrition
After reviewing my medical and lifestyle questionnaires their are only a few areas of
concern that I will address in my program. My medical history is very good, with the exception
of a history of heart problems related to obesity and cancer in my immediate family. With this
information it is important I understand the signs and symptoms of these medical issues and go
to the doctors regularly. I also had knee surgery in High School, I have not had any issues with it
and I have played four years of college soccer without any problems, however I still keep an eye
on it.
I am 22 years old, 5’8” tall and weigh around 160 pounds. When I test my BMI using the
height and weight formula, I am considered overweight. However, this formula is not very
accurate. My body contains a lot of muscle tissue from working out a lot, and the BMI test does
not take into consideration muscle. According to the ACSM risk classifications I am considered
“low risk”. I do not have any risk factors, which means that I do not need medical clearance or
physician supervision during any type of exercise.
Strengths
muscular strength
determination
dedication
flexibility
cardiovascular endurance
Weaknesses
body composition
vertical jump
speed
agility
2. Goal Setting :
I would like to increase my speed my reducing my 50 yard dash time from 6.5 seconds to 6
seconds flat.
I want to lose around 10 pound of body fat to achieve the weight of 150 pounds over a longer
period of time to maintain a healthier me.
Although my agility test gave me average results I find that I could still use some improvement .
I would like to improve this by continuing doing ladder work regularly.
I would also like to improve my eating habits by reducing the amount of late night snacks,
sugars, and bad fats I take in. It is important that with the history of overweight family members
that I eat properly so that I do not increase my risk of high cholesterol and high blood pressure.
3. The Plan
The main reason I want to develop a workout plan is because I want to be a personal
trainer in the near future. I am also going to be a health and physical education teacher,
understanding the body, how it works, and how to maintain a healthy active lifestyle is critical in
being a successful education. It is equally important that I understand how to create a successful
workout plan and more importantly understand why is it essential in the success of a client as a
personal trainer. I am going to focus on my goals when developing my ten week workout plan. I
plan to achieve all of my goals, maintain my strengths, and build upon my weaknesses. I have
always wanted to improve on my nutrition habits and become an overall healthier person.
Focusing on my strengths, I will continue to utilize my muscular strength and build more
muscle tissue so that it will potentially raise my BMR which will in turn help increase my
metabolism. Another strength I have is flexibility. Flexibility is the most overlooked health
related component of fitness. Increased flexibility is proven to increase performance. I will
continue to keep my hamstring and hip flexibility, and improve on my upper body flexibility so
that I can perform at my maximal capability. Another strength I will focus on is my
cardiovascular endurance. I have obtained good cardiovascular endurance through many years of
playing soccer and training. I will use this to be able to push myself in other fitness areas. I will
also use this to try and obtain better overall speed and quickness.
Focusing on building my weakness will be something I have to concentrate on and
overcome. I do not like not being good at something, so I will use my dedication and
determination to push through and succeed. One of my weaknesses is body composition. I have
always been a thicker person, however, I have played sports all my life and have been very
muscular. I am done playing college soccer, and although I will continue to workout and play
sports my body is going to be going through changes. I will change the way I eat and alter my
workouts to my new lifestyle. For example, instead of lifting for power and muscular strength, I
will train to obtain muscular endurance and tone. I will also have to overcome my weaknesses in
speed and agility. Although I tested average on the side jump and 50 yard dash test I have area
for improvements in both areas. Agility and speed are important skill that can be beneficial for
sports, and also can help improve body composition. For example, during sessions like velocity,
which are quick paced, high intensity workouts that focus on skills like agility, power, balance,
speed, and muscular strength you can burn a lot of calories in a short amount of time.
I will be implementing a weekly plan of cardiovascular and muscular fitness along with
proper nutrition habits. I will be utilizing my background knowledge to put together an effective
plan so that I can reach my goals at the end of the ten week program. I will be blogging weekly
about my plan for the week and then reflecting at the end of the week to monitor my progress.
4. Final Analysis
Overall my ten week work out program was a success. I made an improvement in all
areas except balance where I stayed the same. Although I was successful in my program it was
very difficult to stay on track and follow my plan completely. I was a full time student, worked
two jobs, and played soccer. However, it was a good challenge to juggle multiple things, as my
clients in the future, or students I will have will also face the same challenges. It was very
beneficial to blog weekly and reflect on my progress. This gave me an opportunity to change
anything that was not working, or continue to do things that were successful. Although I did not
achieve all of the goals I set for myself I made strides. I plan to continue striving for these goals
and implement the strategies that worked for me, while changing the strategies that were not
successful. The working out part has always been easy for me it is something that I love to do,
however the nutrition aspect has been something that I never had to worry about. Now that I
have gained more knowledge in nutrient timing and nutrition as it relates to exercise I can focus
more on the nutrition aspect, which was also be easier to accomplish once I have finished the
semester and have more time. I would also specifically like to start toning rather than building
more muscle to try and slim down and lose body fat. I will continue to record my results so that I
can see the progress I have made. This was the first time I had followed a workout plan that I had
specifically made for myself. I have followed ones from coaches or trainers, and have even made
them for other people, but it was a challenge to make and follow one for myself. I learned a lot
and it was an important skill that I will utilize greatly in the near future.