LIFESTYLE QUESTIONNAIRE
Please fill out this form as completely as possible.
If you have any questions, DO NOT GUESS! Ask for me assistance.
Name
Date
Month Day Year
Date
Physical Activity
1. In the last 12 months how often have you participated in some kind of exercise?
3 to 4 times per week 1 to 2 times per week 1 to 2 times per month Not at all. i.e. may have been due to pregnancy or ill health
2. What sport/activity or exercise plan has worked for you in the past?
3. What type of exercise do you enjoy and where do you go to take exercise?
4. What form of sport or exercise do you dislike and why?
Occupation / Leisure
5. What is your present occupation and is it full time?
6. Does your occupation involve much physica exercise i.e. lifting,
7. What exercise or hobbies do you like to do in your spare time?
Stress & Sleep
8. Rate your quality of sleep on a scale of 1 – 10. 1 poor and 10 extremely good.
9. How important to you is a good nights sleep?
10. Rate yourself on a scale of 1 – 10. 1 being calm 10 super stressed out.
11. What situations make you feel stressed?
12. How do you calm down & relax?
Diet
13. Do you think you eat a healthy diet?
14. Do you eat 3 meals a day?
15. Do you snack in between meals and if so what do you have?
16. Do you think you eat more than you need?
17. How many calories do you think you consume in a day?
18. How many litres of water do you drink in a day?
Weight
19. Do you consider yourself overweight or a healthy weight?
20. If you answered overweight, how much would you like to loose?
21. Is the rate at which you loose weight important to you?
Fitness
22. Rate yourself on a scale of 1 – 10 as to how fit you think you are
23. Rate your stamina on a scale of 1 - 10
24. How strong do you think you are?
25. How flexible do you think you are?
26. How co-ordinated do you think you are?
27. How much time will you have to do exercise?
Goals
28. What do you want exercise to do for you in the next
1 month
3 months
1 year
29. Rate your goals in undertaking exercise 1 - 10. 1= not important 10= extremely important
30. Rate in your view, the following in importance 1 – 10.
a. Improve overall health
b. Improve your fitness
C. Reshape or tone my body
D. Improve my performance for a particular sport
E. Improve mood and stress levels
Equipment
What equipment do you have available at home?
Are you a member of a gym?

LIFESTYLE QUESTIONNAIRE

Physical Activity

Occupation / Leisure

Stress & Sleep

Diet

Weight

Fitness

Goals

Equipment