Lifestyle and Health History Questionnaire

Name

Phone

Email

Exercise

What exercise activities do you currently take part in?

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

On a scale of 1 - 10, with 1 being low importance, and 10 being very important, how important are the following fitness goals to you?

Weight Loss

Muscle Gain

Sports Performance

Health Improvement

Diet

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

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:

Low

Medium

High

How would you rank your daily sugar intake:

Low

Medium

High

How would you rank your daily fat intake:

Low

Medium

High

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

How many alcoholic drinks do you consume per week?

Do you consume caffeinated beverages such as coffee, tea, soda, and/or energy drinks? If so, how many per week?

Lifestyle

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

On a Scale of 0 - 10, how would you rate your average level of stress?

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

Do you smoke tobacco or use a vaporizer alternative?

Occupation

What is your occupation?

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

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

Does your occupation require you to wear shoes with a heel, such as dress shoes or work boots?

Recreation

Do you participate in any recreational physical activities?

Do you have any additional hobbies?

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 or Explanation

I declare that the info I’ve provided is accurate and complete.

Signature

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Step 3

Lifestyle and Health History Questionnaire

Exercise

Diet

Lifestyle

Occupation

Recreation

Medical