Exercise History, Lifestyle & Goals Questionnaire

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Exercise History, Lifestyle & Goals Questionnaire Powered By Docstoc
					                          NEW CLIENT QUESTIONNAIRE
Please take your time and answer each question honestly, accurately and completely. This is the
only way I can insure that I’m providing you with the most appropriate program customized
specifically for you.

General Information
Full Name: _____________________________________________________________________
Age/DOB: _________________________ Height: ________________ Weight ________________
Mailing address: _________________________________________________________________
E-mail address: _________________________________________________________________
Phone: (H):_____________________ (W) _____________________ (C)____________________

Health / Medical Information
1. Y__N__ Are you currently under the care of a physician? If yes, please explain.
   ___________________________________________________________________________
   ___________________________________________________________________________
   ___________________________________________________________________________

2. Y__N__ Have you been instructed by a physician to start an exercise program? If yes, please
   explain.
   ___________________________________________________________________________
   ___________________________________________________________________________
   ___________________________________________________________________________

3. Y__N__ Are you currently taking medication? If yes, please list.
   ___________________________________________________________________________
   ___________________________________________________________________________
   ___________________________________________________________________________

4. Y__N__ Have you had any accidents, injuries or surgical procedures in the past 10 years? If
   yes, please provide details.
   ___________________________________________________________________________
   ___________________________________________________________________________
   ___________________________________________________________________________
   ___________________________________________________________________________
   ___________________________________________________________________________

5.    Y__N__ Do you have any ailments, allergies or any other medical condition that I should be
     aware of? If yes, please list.
     ___________________________________________________________________________
     ___________________________________________________________________________
     ___________________________________________________________________________
     ___________________________________________________________________________
     ___________________________________________________________________________
              GOAL SETING APPOINTMENT QUESTIONNAIRE
1. Do you consider yourself?
_____ Sedentary (little, if any, vigorous physical activity)
_____ Lightly active (sporadic workouts, lawn work, other kinds of activity; little aerobic)
_____ Moderately active (work out 1-2 days per week for at least 15-30 minutes / day; aerobic
       work)
_____ Highly active (work out 3 or more days / week, at least 30-45 minutes / day; aerobic work)

2. How many minutes per week do you spend in exercise?
_____ 0 _____ 1-15 _____ 15-30 _____30-60 _____ 61-90_____ 91-120 _____ 121-180
_____ 181 and above

3. How many days per week can you commit to an exercise program? ____________________
4. How many minutes per day can you commit to an exercise program? ___________________
5. What are your personal barriers to exercise?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

6. How physically fit are you?
_____ Not                        _____ Less than average         _____ Average
_____ Above average              _____ Outstanding               _____ Don’t know

7. What is your occupation?_____________________________________________________
     Is your occupation _____ Sedentary _____ Semi-active _____ Active
     What is your weekly work schedule?_____________________________________________
      __________________________________________________________________________
7b. If going to school please provide school schedule.___________________________________
    ___________________________________________________________________________

8. Indicate the main reason why you exercise or want to start exercising. (select only one).
_____ I do not exercise.         _____ It is good for my health.
_____ It makes me feel good. _____ I am required to exercise.
_____ I’m trying to lose weight. _____ My doctor told me to exercise.
Other: _______________________________________________________________________

9. Do you frequently participate in competitive sports? _____ yes_____ no
If yes, please list
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

10. Did you or do you participate in high school or college athletics? ___ yes ___ no
If yes, please list. _______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
11. What activities would you prefer in a regular exercise program for yourself?
_____ Walking and / or running            _____ Tennis            _____ Bicycling / spinning
_____ Swimming                            _____ Jumping rope      _____ Handball / racquetball
_____ Basketball                          _____Volleyball         _____ Group Exercise

12. What time do you get up in the morning?______ Go to bed at night?______
  12b. How many successive hours of restful sleep do you get per day?         _____________
  12c. How would you describe your quality of sleep? _                 _________

Comments:
______________________________________________________________________________
______________________________________________________________________________

Dietary Patterns
14. How many meals and/or snacks do you have per day? _______________________________
15. How many ounces of the following do you have per day?
     Milk____ Juice____, Water____, Coffee____, Soda____, Tea____, Beer/Wine/Alcohol____

Please provide a three day detailed food, beverage and activity journal on the documents
provided. Please be very specific regarding the details of what you ate and drank the
amount and time of day it was consumed.

16. What would you like to accomplish? What is your overall goal?
______________________________________________________________________________
______________________________________________________________________________

19. What are your 3 – 6 month goals?
______________________________________________________________________________
______________________________________________________________________________

20. What are your 6 – 9 month goals?
______________________________________________________________________________
______________________________________________________________________________

21. What are your 9 – 12 month goals?
______________________________________________________________________________
______________________________________________________________________________

* Please be advised that I am not a registered dietician or licensed/certified nutritionist. I’m
a certified Sports Nutrition Consultant. I have been following a healthy lifestyle plan since
2003.
If you have any questions, concerns or comments about this questionnaire please feel free to
contact me at 915-443-1278.
                     BEHAVIOR MODIFICATION CONTRACT
Having set a variety of goals you now must determine what behaviors you will need to develop or
maintain to ensure success toward your goals. It is the intermediate steps and behaviors/habits
that will determine whether you achieve or fall short of your goals. Remember, that although
setbacks may occur it is important to learn from setbacks and make the appropriate corrections to
continue on toward your goal. Your personal trainer is here to assist you in reaching your goals.
However, your choices are the ones that will ensure whether your goals are reached. Knowing this,
you are now entering a contract with yourself to modify behaviors that will allow your goals to be
reached. Signing below places the responsibility on you to follow through with the program and
instructions provided.


What behaviors must you modify to ensure success of your goals?
Select the top three (Using the help of the Fitness Specialist/Trainer)
1) _____________________________________________________________________

2) _____________________________________________________________________

3) _____________________________________________________________________

Signed__________________________ Date___________________________________

It is important to realize that trying to make to many changes at once can be overwhelming.
Choosing a few behavior modifications will allow you to focus on a few tasks and not spread
yourself too thin. Once a habit has been formed a new behavior modification can be started.

Notes:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

				
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posted:9/20/2012
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