Lifestyle and Health History Questionnaire
Name
Date
/
Month
/
Day
Year
Date
Age
Gender
Height
Weight
Physician Name
First Name
Last Name
Physician Phone #
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone #
Format: (000) 000-0000.
What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)?
How many days per week do you get at least 60 minutes of moderate intensity exercise?
How many steps per day do you average?
On a Scale 0-10, how important are the following fitness goals to you?
Weight loss
Muscle gain
Sports performance
Health improvement
On a scale 0-10 do you consider your overall diet to be healthy?
Are you currently following a "diet plan" and for what reason?
How would you rank your daily protein intake: low, medium, or high?
How would you rank your daily sugar intake: low, medium, or high?
How would you rank your daily fat intake: low, medium, or high?
How many alcoholic drinks do you consume per week?
Scale 0-10 how effectively are you able to control your temptations for junk food?
Do you consume caffeinated beverages such as coffee, tea, soda, and/or energy drinks? How many per week?
Do you feel like you get enough sleep and wake up feeling rested each day?
Scale 0-10 how would you rate your average stress?
What techniques do you currently use to manage your stress levels?
Do you smoke tobacco or use a vaporizer alternative?
What is your occupation?
Does your occupation require extended periods of sitting? (If YES, please explain.)
Does your occupation require repetitive movements? (If YES, please explain.)
Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots)?
Do you partake in any recreational physical activities? If yes explain
Do you have any additional hobbies?? If yes Explain
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, 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 things I need to know
Preview PDF
Submit
Should be Empty: