Health and Lifestyle Questionnaire

Emergency Contact:*
Please complete the information below for your personal health care provider:*
Please indicate if you have any primary relatives who have any of the following conditions
Please provide a brief explanation for any of the above that have been checked.

Personal Health History
ExcellentGoodFairPoor
Please indicate if you have ever had or currently have any of the following conditions (check all that apply)
Please provide a brief explanation for any of the above that have been checked.
Please indicate if you have had any joint injuries or surgeries that may limit or effect your ability to exercise
Please provide a brief explanation of any of the above that have been checked
Do you have any current or previous injuries of note? If so, do they affect your exercise or day-to-day life?*
Please indicate any medications currently being used and their purpose:
Do you smoke cigarettes?
Are you a past smoker?
Do you drink alcoholic beverages?
Are you presently dieting or on a weight control program?

Activity Background and Goals
YesNo
If yes, please indicate:
minutes of cardiovascular activity, times per week;

minutes of strength or resistance training activity, times per week;

minutes of flexibility training, times per week
Please list your favorite physical activities:*
Please provide a brief explanation of your current exercise program. Include types of activity and frequency:*
What are your current health and fitness goals? Please be as specific as possible:*
Lose weightMaintain weightGain weight
Do you foresee any barriers that may prevent you from adhering to a regular exercise program?*

Personal Health History