Lifestyle/Goals Questionnaire

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1. What is your purpose in participating in an exercise program? What is your overall goal?

2. How long do you believe it will take you to attain your overall goal?

3. How many minutes per day do you spend doing exercise?
01-1530-6061-90+

4. How many days per week do you exercise?

5. What types of activities do you do when you exercise?

6. How many days per week can you commit to an exercise program?

7. How many minutes per day can you commit to an exercise program?

8. What activities would you prefer in a regular exercise program for yourself?
Walking and/or runningSwimmingBasketballTennisJumping ropeVolleyballBicycling/spinningHandball/racquetballGroup exercise

9. What are your personal barriers to exercise?

10. How physically fit are you?
NotBelow averageAverageAbove AverageOutstandingDon't know

11. What is your occupation?

Is your occupation:
SedentarySemi-activeActive

12. Indicate the main reason why you exercise.
I do not exerciseIt is good for my healthIt makes me feel goodI am required to exerciseI'm trying to lose weightMy doctor told me to exercise

13. Do you frequently participate in competitive sports?
yesno

If yes, please list:

14. Did you or do you participate in high school or college athletics?
yesno

If yes, please list:

15. How many successive hours of restful sleep do you have per day?

16. How would you describe your quality of sleep?

Comments:

Dietary Patterns

17. Do you feel you eat healthy most of the time?

18. How many meals and/or snacks do you eat per day?

19. Do you eat breakfast?
yesno

20. How many servings of the following do you partake of each week?
Red meat and eggs:
Fish:
Fried foods:
Poultry:
Vegetables:
Fruit:
Alcohol:
Caffeinated beverages:
Carbonated beverages:

21. How much water do you consume each day?
ounces

22. Is there anything else that we need to know in order to help you attain your goal?

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