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Lifestyle Assessment & History Form
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Your Name
*
Your answer
Your Email
*
Your answer
How often do you check email?
Multiple Times Each Day
One Time Each Day
Every Couple of Days
Once Each Week
Every Couple of Weeks
Never, I Don't Use Email
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Your Street Address
*
Your answer
City, State, Zip
*
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Your Age
Your answer
Your Height
Your answer
Current Weight
Your answer
Your Weight 6 Months Ago
Your answer
Your Weight 1 Year Ago
Your answer
Your Occupation
Your answer
Hours per week at your occupation
Your answer
Does your occupation require much activity (i.e. walking, getting up and down, carrying things)?
Your answer
What are your usual leisure activities?
Your answer
What role does exercise play in your life?
Your answer
What are your personal barriers to exercise (i.e. your reasons for not exercising)?
Your answer
Do you take any supplements or medications? If so, which?
Your answer
Do you have any injuries or pre-existing medical conditions we should be aware of? Recent surgery?
Your answer
Do you drink coffee, smoke cigarettes, or have any major addictions?
Your answer
What is your chief concern?
Your answer
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