Health Survey

Complete all health and fitness status questions. Ask for assistance from your
parents or guardians if needed.

Personal Information
Height 5’ 5”
Weight 134 lbs

Health Status

1. 1. Yes_____ No______ Do you have any medical situation that would limit your
participation in any physical activity?
*If yes, please write a detailed explanation of the medical issue and the specific
activities you cannot participate in.

2. Rate your present medical condition:

_____ Excellent _____ Good _____ Fair _____

Poor
*If you selected Fair or Poor and you do not have a condition that is explained in
item #1, explain why you have rated yourself in this way.

3. Describe two or more physical activities you participate in outside of a school

setting. They could be within your city, community, neighborhood or family. Include
how often you participate, such as a daily or weekly basis.
On the weekdays, I go to EOS Fitness to lift weights and I go on weekly bike rides.

4. Explain how your friends positively and negatively influence your decisions to be
physically active and to make healthy choices.
I feel like my friends are the reason why I am active because they influenced me to
start working out.

5. What areas of your health and body would you like to improve?
_____ Flexibility
_____ Cardiovascular endurance
_____ Upper body strength
_____ Lower body strength
_____ Body composition
_____ Increase weight
_____ Decrease weight
_____ Decrease percentage of body fat
_____ Increase physical activity level