Fitness Health Assessment Form Page 3
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4General Questions
1. Do you have any children?
Yes
How many?____________ Ages_______________________
No
2. Are you currently active?
Yes
No
3. Do you partake in any recreational activities (golf, tennis, skiing, etc.)?
Yes___________________________________________________
No
4. Do you have any hobbies (reading, gardening, working on cars, surfing the web)?
Yes___________________________________________________
No
5. Do you smoke? If so, how many per day?
Yes___________________________________________________
No
6. Do you drink caffeine? If so, how many drinks per day?
Yes___________________________________________________
No
7. Do you drink alcohol? If so, how many drinks per day?
Yes___________________________________________________
No
8. Have you ever worked with a trainer? If so, where and for how long?
Yes___________________________________________________
No
Nutritional Questions
1. Typically how many meals do you eat per day?_______________________________________________
2. Do you know approximately how many calories you consume per day?_____________________________
3. Are you currently taking a multivitamin or other dietary supplements?______________________________
___________________________________________________________________________________
4. Typically how many meals do you eat outside the home per week?_________________________________
5. On a scale of 1-10 how would you describe your current diet (1 being poor – 10 being healthy)?_________
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