Lifestyle & Health History Questionnaire
CLIENT PERSONAL INFORMATION
Name
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First Name
Last Name
Date
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Month
-
Day
Year
Date
Age
*
Gender
*
Height
*
Weight
*
Physician Name
*
Physician Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
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EXERCISE
What exercise activities do you currently take part in (e.g. running, weightlifting, group exercise, etc.)?
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How many days per week do you get at least 60 minutes of moderate-intensity exercise?
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On a scale of 0 to 10, how important is WEIGHT LOSS to you?
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On a scale of 0 to 10, how important is MUSCLE GAIN to you?
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On a scale of 0 to 10, how important is SPORTS IMPROVEMENT to you?
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On a scale of 0 to 10, how important is HEALTH IMPROVEMENT to you?
*
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DIET
On a scale of 0 (not very healthy) to 10 (very healthy), how would you rate your overall diet?
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Are you currently following any kind of diet? If so, what diet and for what reason(s)?
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How would you rank your daily salt intake: low, medium, or high?
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Please Select
low
medium
high
How would you rank your daily sugar intake: low, medium, or high?
*
Please Select
low
medium
high
How would you rank your daily fat intake: low, medium, or high?
*
Please Select
low
medium
high
On a scale of 0 to 10, how effectively are you able to control your temptations for junk food?
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How many alcoholic drinks do you consume per week?
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Do you consume caffeinated beverages such as coffee, tea, soda, and/or energy drinks? How many per week?
*
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LIFESTYLE
Do you feel like you get enough sleep and wake up feeling rested each day?
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On a scale of 0 to 10, how would you rate your average level of stress?
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What techniques do you currently use to manage your stress levels?
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Do you smoke tobacco or use a vaporizer alternative?
*
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OCCUPATION
What is your occupation?
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Does your occupation require extended periods of sitting? (If YES, please explain.)
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Does your occupation require repetitive movements? (If YES, please explain.)
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Does your occupation require you to wear shoes with a heel (e.g. dress shoes, work boots)?
*
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RECREATION
Do you partake in any recreational physical activities (e.g. golf, skiing, etc.?) (If YES, please explain.)
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Do you have any additional hobbies (e.g. gardening, fishing, music, etc.?) (If YES, please explain.)
*
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MEDICAL
Please list out any past musculoskeletal injuries:
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Please list out any past surgeries:
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If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity?
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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.)
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Are you on any medications, and if so, have you received clearance from your doctor to take part in physical activity?
*
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