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Current Lifestyle Questionnaire

Do you have an ergonomically set up desk/workstation?
On a scale of 1-10 (1=not active, 10=very active), please select how active your are on a daily basis
On a scale of 1-10 (1=not active, 10=very active), please select how active your are on a daily basis
Select all the activities you interested in...
Do you consider yourself to be under stress?
Do you smoke?
Do you drink alcohol?
Do you follow, or have you recently followed, any specific dietary intake plan?

How much of the following do you consume in a day?

Please give a brief description of your current food diary snap shot...

Please list THREE goals, in order of importance...

What is the biggest challenge you must overcome to attain your goal?

What is the biggest challenge you must overcome to attain your goal?
On a scale of 1-10 (1=not committed, 10=very committed), please rate how committed you are to your goals

List three tasks you can do to pave the path towards total achievement.

Have you ever had a Personal Trainer before?

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had a chest pain when you were not doing physical activity?
Do you lose your balalnce because of dizziness or do you ever lose conciousness?
Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart?
Do you know of any other reason why you should not do physical activity?

YES TO ONE OR MORE QUESTIONS:

You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

NO TO ALL QUESTIONS:

It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A physical performance assessment can help determine your ability levels. 

Complete all fields before you proceed!

Thank you for completing!

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