Health & Lifestyle Questionnaire Goal Profile Lifestyle Profile

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