Lifestyle QuestionaireLifestyle QuestionnaireLifestyle Questionnaire Name Email Occupation Average Hrs. Worked Per Week first section for notes How do you spend most of your time at work? Standing Sitting Active OtherOther Notes spend most of your time at work notes When you wake up are you: Tired and find it difficult to pull yourself out of bed Refreshed and ready to start the day OtherOther Notes when you wake up notes Would you characterize your life as Highly Stressful Moderately Stressful Low in Stress Notes stressful life notes How would you consider your body weight? Underweight Ideal Bit Overweight Very Overweight Notes consider body weight notes What does your typical day look like SectionWhat does your typical day look like? Wake UP 121234567891011 : 0030 AMPM Work Times: From: 121234567891011 : 0030 AMPM To: 121234567891011 : 0030 AMPM Evening Activities 121234567891011 : 0030 AMPM To: 121234567891011 : 0030 AMPM Activities: Go to Bed 121234567891011 : 0030 AMPMnext notes section How would you describe your current activity level? Sedentary Moderately Active Active Highly Active Notes Current activity notes How would you rate your present level of fitness? Unfit Moderately Fit Highly Trained Notes Present level of fitness notes Have you ever had a personal trainer? Yes No How long ago? How often did you train? Once a week 2 X Week 3 X Week 4 X Week 5 X Week 6 X Week Every Day 1-1 / Group? 1 on 1 Group OtherOther Do you currently exercise? Yes No Any previous regular exercise? Yes No How long have you been training? A few weeks A few months Around one year What type of exercise do you do? How long is each training session? 1/2 Hour 1 Hour 1 1/2 Hours 2 Hours Longer than 2 Hours Were do you exercise Gym Home Swimming Pool OtherOther What time of day do you normally train? Morning Afternoon Evening Night Do you participate in any sports? Yes No What Sports? What fitness equipment do you have access to? Commercial Gym Cable Machines Free Weights Kettle Bells OtherOther How much time will you have to exercise each week? 1 Hour 2 Hours 3 Hours 4 Hours 5 or More Hours What did/ do you like least about exercise? What did/ do you like about exercise? How many meals do you eat each day? 1 2 3 4 5 6 Notes eat meals day notes Do you ever skip meals? Yes No Notes skip meals notes Which ones and how regularly? eat meals sectionWhat time of day do you usually eat your meals? Breakfast 121234567891011 : 0030 AMPM Snack 121234567891011 : 0030 AMPM Lunch 121234567891011 : 0030 AMPM Snack 121234567891011 : 0030 AMPM Dinner 121234567891011 : 0030 AMPM Snack 121234567891011 : 0030 AMPMlast section How large is your typical meal? Small Medium Large Extra Large OtherOther Notes large is your meal notes Do you ever get hungry between meals? Yes No Sometimes Notes get hungry between meals notes Do you take any supplements? Yes No What supplements? Are you currently on a diet? Yes No Which Diet? How would you rate your eating habits? Poor Average Good Very Good Notes eating habits notes On Average how many portions of Vegetables do you eat each day? 0 1 2 3 4 5+ On average how many portions of Fruit do you eat each day? 0 1 2 3 4 5+ If you snack or have any weaknesses, what do you generally tend to eat/drink? How many alcoholic units do you drink per week? 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24+ 1 unit = WINE 1 glass, BEER 1/2 pint How many ounces of water do you drink each day? 8 Glasses = 64 oz (1/2 Gallon) 1 Gallon = 128 ozControllable Dietary Health Risk Habits Coffee Fizzy Drinks Sugar Chocolate Alcohol Salt Red Meat Fried Food Drugs Tobacco Dairy Products Low Fiber Intake SubmitΔ
