Assessing and Advising on Lifestyle Factors
Health & Lifestyle Questionnaire
Name:
DOB:
Age:
Address:
Phone Number:
Occupation:
Emergency Contact & Relationship:
Doctor:
Doctor’s Address:
PAR-Q
Do you ever lose your balance or consciousness?
Do you frequently have pains in your chest when you perform in physical activity?
Do you have any history of heart problems?
Have you ever had pains in your chest when you were not performing exercise?
Lifestyle Questions
Do you smoke?
Do you drink alcohol?
How many hours do you usually sleep at night?
Is your job sedentary, active, or physically demanding?
Does your job require travel?
Have you ever been overweight?
Do you exercise regularly?
What is your fitness level like?
Have you ever had injury problems?
How would you rate your diet?
How many meals do you eat a day?
How much water do you drink a day?
How regularly do you exercise a week?
Goal setting
What do you want to achieve?
How committed are you?
Anything stopping you from achieving your goals?
Health & Lifestyle Questionnaire
Name:
DOB:
Age:
Address:
Phone Number:
Occupation:
Emergency Contact & Relationship:
Doctor:
Doctor’s Address:
PAR-Q
Do you ever lose your balance or consciousness?
Do you frequently have pains in your chest when you perform in physical activity?
Do you have any history of heart problems?
Have you ever had pains in your chest when you were not performing exercise?
Lifestyle Questions
Do you smoke?
Do you drink alcohol?
How many hours do you usually sleep at night?
Is your job sedentary, active, or physically demanding?
Does your job require travel?
Have you ever been overweight?
Do you exercise regularly?
What is your fitness level like?
Have you ever had injury problems?
How would you rate your diet?
How many meals do you eat a day?
How much water do you drink a day?
How regularly do you exercise a week?
Goal setting
What do you want to achieve?
How committed are you?
Anything stopping you from achieving your goals?
