Lifestyle Questionnaire

Sam Thornton Personal Training Lifestyle Questionnaire

 

Date of Consultation:………./………./……………

First name……………………………………………….Surname………………………………………………………………….

Date of birth…………/…………/…………………Address…………………………………………………………………….

……………………………………………………………………………….PostCode………………………………………

Tel no………………………………………………………… Email address………………………………………………

 

( Information will be treated in the strictest confidence. For most people physical activity should not pose any health problems. This medical questionnaire is designed to identify areas which may affect your ability to exercise safely, and it may be appropriate to arrange for consent from your General Practitioner.)

Medical History

  1. Have you ever had a heart condition or experienced chest pain, either at rest or during activity? Yes/no
  2. Have you ever had a stroke, epilepsy, vertigo, dizziness or loss of consciousness? Yes/no
  3. Do you feel breathless at rest or with mild exertion? Do you have asthma, chronic obstructive pulmonary disease or any other breathing problems? Yes/no
  4. Have you been diagnosed with abnormal blood pressure by your doctor? Yes/no
  5. Are you currently taking any prescribed medication? Yes/no. If yes please list……………………

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6. Do you have any bone, joint or soft tissue disorder which affects your ability to exercise? Yes/no. If yes please list…………………………………………………………………………………………………………………………………………………………..

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7. Do you have any medical conditions, injuries or have had any surgery which may affect your ability to exercise? Yes/no. If yes please list……………………………………………………………………………………………………………………………..

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8. Do you currently smoke or have you ever smoked? Yes/no. If yes how many per day or how long has it been since you gave up?…………………………………………………………………………………………………………………………………………….

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Well being check

 

  1. How would you describe your energy levels throughout the day?…………………………………

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2 .How much sleep do you get on average each night?…………………………………………………………….

3. Do you have regular bowel movements?…………………………………………………………………………………………….

4. How happy are you in your personal life on a scale of 1-10 ……………………………………………………………………

5. How happy are you in your professional life on a scale of 1-10…………………………………………………………………

6. Is there anything about your personal  life you would like to change?………………………………………………………

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7. Do you suffer from stress? Yes/no. If yes how do you manage your stress levels?………………………………………..

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8. Is there anything you would like to change about your professional life?………………………

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9. What if anything stops you making these changes?…………………………………………………….

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Exercise questionnaire

  1. On average how many times a week to you exercise at a level where you perspire for at least 20 minutes? Please provide details……………………………………………………………………………………………………………………….

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2. What types of exercise do you enjoy?………………………………………………………………………………………………………

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3. Pleas list any occasions when you have been successful with an exercise program and why you felt it worked for you…………………………………………………………………………………………………………………………………………………………

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4. Have you ever struggled with anything exercise related? Yes/no. If yes please list……………………………………………

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5. What are you health, fitness or sports related goals?

Short term……………………………………………………………………………………………………………………………………………….

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Long term………………………………………………………………………………………………………………………………………………..

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Specific comments to take away from the questionnaire………………………………………………………………………………….

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Nutritional Questionnaire

  1. Please describe a normal day of eating and drinking……………………………………………………………………………..

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2. How many caffeinated drinks do you drink each day?………………………………………………………………………………….

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3. How many units of alcohol do you drink a week?………………………………………………………..

4. Do you have any food allergies, intolerances or specific dietary requirements? Yes/no. If yes please list…………………………………………………………………………………………………………………………………………………………..

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5. Do you have any particular likes or dislikes?………………………………………………………………………………………………

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