"Lifestyle Assessment Form"

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Lifestyle Assessment Form
Congratulations on taking the first step towards leading a healthier lifestyle! Please take a few moments
to complete the questionnaire below. All information is kept confidential according to the Personal
Information Protection and Electronic Documents Act (PIPEDA).
SECTION A: Personal Information
First Name:
___
Last Name:
Mailing Address:
___
Date of Birth:
Age:
Gender: Male
Female
Height:
ft
in OR
cm
Weight:
lbs OR
Kg
Contact Information: (please indicate preference)
Daytime: Phone:
Email:
Evening: Phone:
Email:
SECTION B: My Lifestyle and Fitness Goals
Please select all that apply:
Healthy weight loss
Improve overall health
Improve flexibility
Healthy weight gain
Prevention of disease
Address medical conditions
Increase physical activity
Increase strength
Other:
________________
Make better food choices
Increase physical endurance
Target Weight:
Target Date for Attaining Weight Goal:
SECTION C: Medical History
Do you currently experience the following symptoms or have been diagnosed with the following medical conditions? Please check
all that apply:
Allergies
__________________
Digestive Health (IBS, Chrone’s)
Joint Pain
Anxiety and Stress
Osteoporosis, Osteoarthritis
Heart Disease
Asthma
Low Back Pain
High Cholesterol
Depression
Neck Pain
Migrane, Headaches
Diabetes Type 1
Chronic Muscle Soreness
Other
Specify:
Diabetes Type 2
Injuries
___________________
_______________________
Are you pregnant?
No
Yes Anticipate Due Date:
________________________________
Do you currently smoke?
No
Yes
If yes, how many cigarettes / cigars per day?
___
Have you ever smoked?
No
Yes
For how long?
Does anyone else smoke in your household?
Yes
No
Your workplace?
Yes
No
Family history:
Hereditary diseases:
_____________________________________________________
Health of relatives: Please indicate any medical conditions that you are aware of.
Father:
____________________________________ Mother:
_______________________________________
Siblings:
______________________________________________________________________________________
Have you ever been hospitalized?
No
Yes
What was the reason?
____________________________
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Lifestyle Assessment Form
Congratulations on taking the first step towards leading a healthier lifestyle! Please take a few moments
to complete the questionnaire below. All information is kept confidential according to the Personal
Information Protection and Electronic Documents Act (PIPEDA).
SECTION A: Personal Information
First Name:
___
Last Name:
Mailing Address:
___
Date of Birth:
Age:
Gender: Male
Female
Height:
ft
in OR
cm
Weight:
lbs OR
Kg
Contact Information: (please indicate preference)
Daytime: Phone:
Email:
Evening: Phone:
Email:
SECTION B: My Lifestyle and Fitness Goals
Please select all that apply:
Healthy weight loss
Improve overall health
Improve flexibility
Healthy weight gain
Prevention of disease
Address medical conditions
Increase physical activity
Increase strength
Other:
________________
Make better food choices
Increase physical endurance
Target Weight:
Target Date for Attaining Weight Goal:
SECTION C: Medical History
Do you currently experience the following symptoms or have been diagnosed with the following medical conditions? Please check
all that apply:
Allergies
__________________
Digestive Health (IBS, Chrone’s)
Joint Pain
Anxiety and Stress
Osteoporosis, Osteoarthritis
Heart Disease
Asthma
Low Back Pain
High Cholesterol
Depression
Neck Pain
Migrane, Headaches
Diabetes Type 1
Chronic Muscle Soreness
Other
Specify:
Diabetes Type 2
Injuries
___________________
_______________________
Are you pregnant?
No
Yes Anticipate Due Date:
________________________________
Do you currently smoke?
No
Yes
If yes, how many cigarettes / cigars per day?
___
Have you ever smoked?
No
Yes
For how long?
Does anyone else smoke in your household?
Yes
No
Your workplace?
Yes
No
Family history:
Hereditary diseases:
_____________________________________________________
Health of relatives: Please indicate any medical conditions that you are aware of.
Father:
____________________________________ Mother:
_______________________________________
Siblings:
______________________________________________________________________________________
Have you ever been hospitalized?
No
Yes
What was the reason?
____________________________
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SECTION D: Activity Levels
Please select one:
Sedentary (no exercise-gardening or house work etc.)
Moderately active (3 to 5 times/week 20-30 minutes each time)
Active (3 to 5 times/week 60 minutes each time)
Very active (3 to 5 times/week 90 minutes each time. Competitive recreational athletes )
Extremely active (5 or more times /week 90 minutes plus per session. Pro athletic level)
List types of exercise:
____________________________________________________________
What are you main hobbies and recreation?
______________________________________________________________________________________________________
How many hours a day do you watch television?
________________
How many hours do read?
_____________
How many hours of sleep do you get on average?
_________
Do you awaken feeling rested?
___________________
How many hours do you work each day?
_______________
Do you enjoy your work?
_______________________
How many hours do you spend in front of a computer?
____________
Rate the level of stress you are experiencing now; 0 is no stress, 10 is unbearably stressed.
The source of your stress is:
Financial
Job-related
Interpersonal
Marriage
Health
Unfulfilled expectations
Family members
Spiritual
Other
____________________________
SECTION E: Eating Habits
I consume/eat the following: Check all that apply.
Sugar substitutes (Nutra-Sweet etc.)
5 Vegetables or Fruits per day
Vitamins/minerals
Candy
Carbonated beverages
Salmon
Fried foods
Fast foods
Chocolate
Red Meat
White flour (eg: pasta, bread)
Potato chips
Chewing gum
Whole grain products
Green Vegetables
Luncheon meats
Margarine
What medications and supplements are you taking now? ( vitamins, minerals, herbal remedies, prescription drugs, etc. )
How many cups/bottles/glasses do you drink, on average, per day?
Coffee
Milk (2%)
Soft drinks (diet)
Herbal tea
Liquor
Tea
Milk (skim)
Soft drinks (reg
Beer
Water
Fruit juice
Vegetable juice
Wine
Thank you completing this Lifestyle Assessment Form. Please send this form via email to
Lean4Life@acclaimability.com
or via fax
to 1-866-486-8663. A Health Coach will contact you shortly to discuss your Fitness and Lifestyle Goals.
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