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EXERCISE HISTORY QUESTIONAIRE
EXERCISE HISTORY AND ATTITUDE QUESTIONAIRE
Name:

Date:
Please answer the following questions closest to your ideal answers.
1.
  Please rate your exercise level on a scale of 1 to 5 (5 indicating very strenuous) for each age range through your present age:
   
 
1
2
3
4
5
 
 12 - 15
 16 - 20
 21 - 30
 31 - 40
 41 - 50
 51 Above
2.
  Were you a Secondary school, college or University athlete?
   
  Yes No
  If yes, what sport(s)
3.
  Do you have any negative feelings toward, or have you had any bad experience with physical activity programs?
   
  Yes No
  If yes, please elaborate
4.
  Rate yourself on a scale of 1 to 5 (1 = low and 5 = high)
   
  Characterize your present athletic ability.
 
1 2 3 4 5
   
  When you exercise, how important is competition (doing the best you can)?
 
1 2 3 4 5
   
  Characterize your present cardiovascular capacity.
 
1 2 3 4 5
   
  Characterize your present muscular capacity.
 
1 2 3 4 5
   
  Characterize your present flexibility capacity.
 
1 2 3 4 5
5.
  Do you start exercise programs but then find yourself unable to stick with them?
   
  Yes No
  If yes, please elaborate
6.
  How much time are you willing to devote to an exercise program?
   
  minutes/day days/week
7.
  Are you currently involved in regular endurance (cardiovascular) exercise?
   
  minutes/day days/week
   
  Please rate your perception of the exertion of your exercise program:
 
  Light Fairly Light Somewhat Hard Hard  
8.
  What are other exercise, sport or recreational activities have you participated in?
   
  In the past 6 months?
   
  In the past 5 years?
9.
  Can you exercise during your work day?
   
  Yes No
10.
  Would an exercise program interfere with your job?
   
  Yes No
11.
  Would an exercise program benefit your job?
   
  Yes No
12.
  Would an exercise program benefit your job?
   
 
Walking
Jogging
Swimming
Cycling
Stationary Biking
Racquet Sports
Stair Climbing
Rowing
Other Aerobics
Stretching
Yoga/Pilates
Strength Training
13.
  Discuss your goals in undertaking exercise: What do you want exercise to do for you?
   
 
 
  Rate each goal separately on a scale of 1 - 10 (1 = most important 10 = not at all important):
 
 
1
2
3
4
5
6
7
8
9
10
Improve cardiovascular fitness
Body-fat loss
Reshape or tone my body
Improve performance for a specific Sport
Improve moods and ability to cope with stress
Improve flexibility
Increase strength
Increase energy level
Enjoyment
Others
HEALTH HISTORY
HEALTH HISTORY
Name:

Date:
1.
  Has a physician ever told you have had any of the following? (please indicate yes by placing a tick mark next to the disease).
   
 
Coronary Heart Disease Heart Attack
Epilepsy Congenital Heart Disease
Irregular Heartbeats Diabetes
Heart Valve Problems Angina
Heart Murmurs Cancer
High Blood Pressure Arthritis
High Cholesterol Obesity
Lung Disease (Asthma, Emphysema, etc.)  
Others. Please Specify:
2.
  Has anyone in your immediate family (mother, father, sibling, grandparents) experience any of the above conditions?
   
  Yes No
3.
  Have you ever experienced any of the following?
   
 
Chest Pains/Discomfort
Shortness of Breath
Heart Palpitations
Back Pain
Joint, tendon, or Muscular Pain
Orthopedic Problems
   
  If yes, please elaborate
4.
  Please list any medications that you are currently taking (name & reason):
   
 
5.
  Do you have any medical conditions for which a physician has ever recommended some restrictions on activity (including surgery)?
   
  Yes No
  If yes, please explain
6.
  Are you pregnant?
   
  Yes No
7.
  Do you smoke?
   
  Yes No
  If yes, cigarettes/pipe/cigars per day.
8.
  Have you had your cholesterol measured in the last year?
   
  Yes No
  If yes, what was your HDL level? LDL level?
9.
  Do you drink alcoholic beverages?
   
  Yes No
  If yes, glasses per day times per week.
10.
  Do you normally eat a varied diet with food from the major food groups (meats, fruits, vegetables, grains, milk)?
   
  Yes No
11.
  Is your diet high in saturated fat (milk products, cheese, meats, fried foods, desserts)?
   
  Yes No
12.
  Is your diet high in saturated fat (milk products, cheese, meats, fried foods, desserts)?
   
 
No Stress
Occasional mild stress
Frequent high stress
Constant high stress
13.
  Please describe your current exercise program. List type of activity, number of sessions per week, time per session and intensity level:
   
 
14.
  List Any areas for which you would like additional information:
   
 
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