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Lifestyle Questionnaire
Name: ________________________________________ Date: ______________
How do you rate your current activity level?
______
Sedentary no exercise regimen______
Light 2-3 days/wk planned moderate activity, 30 min sessions______
Moderate 3-5 days/wk planned moderate to vigorous, 30-60 min sessions______
High 5-7 days/wk planned moderate to vigorous, 60 minute sessionsHave you ever participated in exercise in the past? What activities and for how long? _______
________________________________________________________________________
How active are you at your current occupation?____________________________________
What physical activities do you enjoy doing?_______________________________________
What do you dislike?________________________________________________________
What goals do you wish to accomplish with your exercise program?___________________
________________________________________________________________________
Being honest, how much time can you commit to working out? _______days/wk ______min/day
Do you have a tendency to start an exercise regimen and not be able to stick to it? _________
If so, why not?______________________________________________________
Do you have a positive or negative support system with friends, family & coworkers?________
Are you interested in starting your fitness program with a friend or partner?_____________
Do you have any obstacles in your life that will interfere with your commitment to stick to an
exercise program? (travel,kids,etc) _______________________________________
Do you feel you have a good understanding of proper nutrition & food portions?____________