Lifestyle questionnaire This is strictly confidential and will be between us only.

Name___________________ Date_______________

Age_______ Weight__________ Height__________

Any injuries past or present that would affect or limit your performance?

 

On a scale of 1 worst ever to 10 best ever how would you rate your current level of fitness?


How many times per week do you typically take part in physical activities?


If you are presently inactive, when was the last time you exercised regularly?


If presently active, what sorts of activities are you involved in? Strength training, cardio exercise and/or flexibility training (please list)

_______ times a week.

On average how many hours do you sleep per night?


Do you drink an adequate amount of water? (64oz. or more)


Do you drink coffee, tea, soda or diet soda? How much per day?


Please describe any medical/health conditions or diagnosis that may affect your ability to exercise.

 

 

 

 

Do you feel you have any obstacles (actions , behaviors, or activities)that may impede your progress towards accomplishing your goals? For example: inconsistency, not prioritizing your health, not changing your workout program.

 

 

 

 

Give a brief description of your fitness/wellness goals.

 

 

 

 

 

 

Thank you! I look forward to helping you reach your goals!