ACTIVITY 4: Health, Wellness, and Lifestyle Questionnaire

Instructions: Fill in the questionnaire below.

Personal Data
Name:
Phone Number:
Date of Birth:
Sex (Male/Female):

Person to contact in case of emergency

Name:
Phone Number:

The following information is required and will assess your physical fitness level to
establish a customized exercise program. Your health questionnaire and test results are
confidential and not be released to anyone other than yourself.

1. In the past year, how often have you been engaged in physical activity?
2. What type of physical activity do you consider fun?
3. What your personal barriers to exercise?
4. What physical activity have you been successful with in the past?
5. What are your leisure activities?
6. What types of things make you feel stressed?
7. How do you deal with stress?
8. How many meals and/or snacks do you have per day?
9. Do you feel that you eat healthy most of the time?
10. Do you have any negative feelings towards, or have you had any bad experiences with
physical activity programs?
11. Do you start an exercise program but then find yourself unable to stick with them?
12. Are you currently involved in regular exercise?
13. Can you exercise during school or work day?
14. Would it benefit your day-to-day activities?
15. What type of exercise interests you?
16. What do you want exercise to do for you?
17. How much would you like to change your current weight?
18. Anything else you would like you instructor to know?