Health & Lifestyle Questionnaire Goal Profile Lifestyle Profile

Health & Lifestyle Questionnaire
Name (print): Date of Birth(MM/DD/YYYY): Sex:
Address: City: Postal Code: Phone (Home):
( )
Employer (corporate memberships only):
Physician
Physician Phone:
( )
Phone (Work):
( )
Membership Type:
Fitness Racquets
REV
Today’s Date:
Goal Profile
What are the areas you wish to work on or improve? (Circle)
Weight Loss Aerobic Conditioning Muscle Toning Muscle Building
Sports Specific Training Nutritional Wellness Counselling Stress Management
Rehabilitation Strength Other________________________
How many days of the week are you able to commit to your exercise program?
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
What time of day will you be coming in for your workouts?
How much time are you able to commit to your workouts?
Lifestyle Profile
Occupation: Description of Work Performed: Hours worked per week: Number of Days worked
per week:
Do you find your occupation stressful?
Yes No
What recreational activities do you participate in?
Do you drink alcohol? If yes, how many drinks per week:
What do you do for stress relief?
Are you presently exercising?
Yes No
Do you or have you ever smoked? If yes, how long:
Yes No # of years:
Do you drink coffee or tea? If yes, how many per week:
Yes No # of drinks:
How many hours do you sleep per night?
Yes No # of cups:
Do you awaken feeling rested?
How would you rate your energy levels? High, Medium or Low:
Yes
No
Morning: Afternoon: Evening:

Medical Profile
Do you suffer from any of the following: (Circle)
Arthritis Dizziness Neck or Back Pain High Blood Pressure
Hernia Allergies Shortness of Breath Low Blood Pressure
Anemia Rheumatism Heart or Chest Pain Asthma
Emphysema Water Retention Heart Disease Diabetes
Epilepsy Varicose Veins Heart Trouble Irritable Bowel Syndrome
Other: ________________________________________________________
Please list previous injuries, bone or joint problems and any recent surgery:
1.
2.
3.
Are you accustomed to vigorous physical exercise? Yes No
Are you presently taking any form of medication? Yes No
If yes, please List: ____________________________________________________
Are there any other reasons you should not follow an exercise program? Yes No
If yes, please indicate: ______________________________________________
Nutritional Profile
How many of the following meals and what foods have you ate in the last 3 days?
Meal Yes No Day 1 Day 2 Day 3
Breakfast
Mid morning snack
Lunch
Mid afternoon snack
Dinner
Evening snack
Late night snack