Lifestyle and Health History Questionnaire Name * First Name Last Name Email * Date MM DD YYYY Age Gender Height Weight Emergency Contact Name First Name Last Name Emergency Contact Phone (###) ### #### 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? On a scale of 0 to 10, how important are the following fitness goals to you? Weight loss Muscle gain Sports performance Health improvement On a scale of 0 to 10, do you consider your overall diet to be healthy? Are you currently following any kind of diet? If so, what diet and for what reason(s)? How would you rank your daily salt intake: low, medium, or high? Low Medium High How would you rank your daily sugar intake: low, medium, or high? Low Medium High How would you rank your daily fat intake: low, medium, or high? Low Medium High On a scale of 0 to 10, how effectively are you able to control your temptations for junk food? How many alcoholic drinks do you consume per week? 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? On a scale of 0 to 10, how would you rate your average level of 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 (golf, skiing, etc.)? (If YES, please explain.) Do you have any additional hobbies (gardening, fishing, music, etc.)? (If YES, please 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 (such as, but not limited to, cardiovascular disease, pulmonary disorders, hypertension, diabetes, or cancer)? (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? Is there anything else I should know? Thank you!
