Lifestyle and Health History Questionnaire

Client Personal Information

First and Last Name

Phone

Email

Birthday

Month

Day

Year

Sex

Yes

No

Other

Height (feet/inches)

Weight (lbs)

Emergency Contact Name and Phone #

Physician Name and Phone #

Exercise

What exercise activities do you currently take part in (e.g., running, weightlifting, group exercise, etc.)?

How many days per week do you get at least 60 minutes of moderate-intensity exercise?

Describe any recreational activities or hobbies you have.

Diet

On a scale of 1 (not at all healthy) to 5 (completely healthy), do you consider your overall diet to be healthy?

Are you currently following any kind of diet?

Yes

No

If yes, answer the following question.

What diet are you following, and for what reason(s)?

How would you rank your daily salt intake?

Low

Medium

High

How would you rank your daily sugar intake?

Low

Medium

High

How would you rank your daily fat intake?

Low

Medium

High

On a scale of 1 (not at all) to 5 (completely in control), how effectively are you able to control your temptations for junk food?

How many alcoholic drinks do you consume per week?

How many caffeinated beverages (coffee, tea, soda, and/or energy drinks) do you consume per week?

Lifestyle

Do you feel like you get enough sleep and wake up feeling rested each day?

Yes

No

Sometimes

On a scale of 1 (not stressed at all) to 5 (stressed all the time), how would you rate your average level of stress?

What techniques do you currently use to manage your stress levels?

Do you smoke tobacco or use a vaporizer alternative?

Yes

No

Occupation

What is your occupation?

Does your occupation require extended period of sitting?

Yes

No

Does your occupation require repetitive movements?

Yes

No

If yes, answer the following question.

What kind of repetitive movements do you perform?

Does your occupation require you to wear shoes with a heel (e.g., dress shoes, work boots, etc.)?

Yes

No

Medical

Describe any past musculoskeletal injuries.

Describe any past surgeries.

If you have experienced injuries or surgeries, were they properly healed or rehabilitated and did you receive clearance from a doctor to return to physical activity?

Yes

No

Do you have any chronic health conditions (such as, but not limited to, cardiovascular disease, pulmonary disorders, hypertension, diabetes, or cancer)?

Yes

No

If yes, answer the following question.

Describe any chronic health conditions.

Are you on any medications?

Yes

No

If yes, answer the following question.

Have you received clearance from your doctor to take part in physical activity?

Yes

No

Certification

I certify that all information provided in this questionnaire is true, accurate, and complete to the best of my knowledge. I understand that providing false, misleading, or incomplete responses may affect the services, recommendations, or decisions based on this information.

I acknowledge that I have answered all questions honestly and voluntarily. I accept full responsibility for the accuracy of my responses and understand that any misrepresentation or omission may result in consequences, including but not limited to the invalidation of agreements, recommendations, or services rendered based on this questionnaire.

Signature

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Date

Month

Day

Year