Lifestyle Information

Name__________________________________________________ Date____________

Physical Activity

            1. In the past year, how often have you been engaged in physical activity?

                ?  Regularly (3 to 4 times/week)

             ?  Semi Regular (1 to 2 times/week)

             ?  Sporadic (1 to 2 times/month)

             ?  None

            2. What types of physical activity do you enjoy? __________________________

            __________________________________________________________

            3. What are your personal barriers to exercise (i.e., reason for not exercising)?___

            __________________________________________________________

            4. What physical activities have you been successful with in the past?__________

            __________________________________________________________

            5. How do you think your weight affects your daily activities? _______________

            _________________________________________________________

Support

            6. Do you feel any family, friends, or co-workers have negative feelings towards

                your efforts at physical activity? _____________________________________

            ________________________________________________________

            7. Is your significant other or a close friend involved in any regular physical

                activity? ________________________________________________________

            ________________________________________________________

Occupation

            8. What is your present occupation? ____________________________________

            9. Does your occupation require much activity?___________________________

            10. What are your usual leisure activities? _______________________________

Stressors

            11. What types of things make you feel stressed? __________________________

            12. How do you deal with your stress normally? ___________________________

Dietary Patterns

            13. How many meals and/or snack do you have per day? ____________________

            14. What would you estimate your caloric intake to be per day? ______________

            15. Do you feel you eat healthy “most of the time”? ________________________

Expectations

            16. Specifically describe what you would like to accomplish through your fitness

                  program during the next:

              1 month   ________________________________________________________

              4 months _________________________________________________________