Health and Fitness Questionnaire

Client Information

First name

Last name

Birthdate

Month

Day

Year

Gender

Height

(Feet and inches)

Weight

(Pounds)

Physician Name

Physician Phone Number

Exercise

How many days per week do you get 60min of moderate-intensity exercise?

How many days per week do you get 30min of low-intensity exercise?

On average, how many steps do you take per day?

What exercise activities do you currently take part in? (e.g. running, weightlifting, group exercise, etc.)

Do you currently have an exercise routine? If yes, what is it?

Include descriptions for type of exercise each day of the week across a typical week.

On a scale of 0 (low) to 10 (high), how important are the following fitness goals to you? Please list any specific health or fitness goals related to each topic. (Please keep in mine that goals should be SMART - Specific, Measurable, Achievable, Relevant, and Timely)

Weight Loss

Muscle Gain

Sports Improvement

General Fitness/Health Improvement

Diet

On a scale of 0 (low) to 10 (high), do you consider your overall diet to be healthy?

On a scale of 0 (low) to 10 (high), are you able to control your temptations for junk food?

Are you currently following any type of diet (paleo, keto, vegan, vegetarian, etc.)? If so, what diet and for what reason(s)?

Are you currently doing intermittent fasting? If so, for how long?

How would you rate your daily salt intake (low, medium, or high)?

How would you rate your daily fat intake (low, medium, or high)?

How would you rate your daily sugar intake (low, medium, or high)?

How many caffeinated beverages do you consume per day?

How many alcoholic beverages do you consume per week?

Lifestyle

Do you smoke tobacco, vaporizers, or others? If so, how often?

On average, how many hours of sleep do you get per night?

Do you get enough sleep and wake up feeling rested each day?

On a scale of 0 (low) to 10 (high) how would you rate your average level of stress?

What techniques do you currently use to manage your stress (meditation, walks, journaling, etc.)?

Occupation

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? (If yes, please explain)

Does your occupation cause mental stress? (If yes, please explain)

Recreation

Do you take part 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)

Do you have any recreational goals (climb Mt. Rainier, run a 5k, ski a black diamond, etc.? (If yes, please explain)

Medical

Do you have any past injuries, chronic pain, diagnoses, or complications? (If yes, please explain)

Do you have any past surgeries? (If yes, please explain)

If you have experienced injuries or surgeries, were they properly rehabilitated and did you receive clearance from a doctor to return to physical activity?

If yes, did you attend Physical Therapy?

If yes, have you received clearance from your Physical Therapist to take part in physical activity?

What date did you get cleared from Physical Therapy? (*If it was in the last year, please provide written clearance to exercise)

Physical Therapy / Doctor Clearance to Exercise

Do you have any chronic health conditions (such as heart disease, cardiovascular diseases, pulmonary disorders, hypertension, high cholesterol, diabetes, or cancer)? If yes, please explain)

Are you currently taking any medication? (If yes, please list)

Before Photo (optional)

Please take a before photo to be able to compare your results to as you progress in your health and fitness journey. While this is not mandatory, it is highly suggested as a visual way to see your progress over time. (*Note: this photo will never be shared without your permission.)

File upload

Signature

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Date

Month

Day

Year

Health and Fitness Questionnaire

Health and Fitness Questionnaire

Get in Touch

Have questions or comments? Contact us today!

Email: info@motivatedbymovement.com
Phone: (503) 395-5323

Health and Fitness Questionnaire

Health and Fitness Questionnaire

Get in Touch

Have questions or comments? Contact us today!

Email: info@motivatedbymovement.com Phone: (503) 395-5323

Email: info@motivatedbymovement.com
Phone: (503) 395-5323