Healthy Living Questionnaire Template - Ymca At Norton Commons printable pdf download

HEALTHY LIVING QUESTIONNAIRE

YMCA AT NORTON COMMONS

Name: _______________________________________

Date: ___________________________

Phone: __________________________

Email: ________________________________________

Occupation: ___________________________________ Work/School Hours: ______________________

Please list other people in your household and their relationships to you: _________________________

_____________________________________________________________________________________

GENERAL HEALTH INFORMATION

Primary Physician’s Name/Office: _________________________________________________________

Physician’s Phone: ______________________________

Date of most recent exam: ______________

Date of most recent blood/lab tests:_____________***

***If you have recent lab results, please bring them to your appointment

Age: _______Height:________ Weight: ________ BMI: ________ IBW:_ _______ %IBW:________

List all prescription and over-the-counter medications that you currently take (include the dosages): ___

_____________________________________________________________________________________

List all vitamins, minerals, supplements, and herbs that you take: ________________________________

_____________________________________________________________________________________

How often do you use tobacco per week? ________________

How often do you use alcohol per week? ________________

How many hours of sleep do you average per night? __________

Is your sleep restful?

Yes No

On a scale from 1 (low) to 5 (high), how would you rate your daily stress level?

1 2 3 4 5

How do you cope with stress in your daily life? _______________________________________________

Are there any religious practices/beliefs that affect you diet or health care? Please Explain:

Healthy Living Questionnaire Template - Ymca At Norton Commons