Healthy Living Questionnaire Template - Ymca At Norton Commons Page 2
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Do you have any food allergies/intolerances? Please Explain: ___________________________________
_____________________________________________________________________________________
How do you rate your health?
Poor
Fair
Average
Good
Excellent
(Please circle)
On a scale of 1 (Not motivated) to 10 (Highly motivated), how motivated are you to make lifestyle
changes?
1 2 3 4 5 6 7 8 9 10
On a scale of 1 (Not confident) to 10 (Very confident), how confident are you to make lifestyle changes?
1 2 3 4 5 6 7 8 9 10
REVIEW OF SYSTEMS (CIRCLE ALL THAT YOU CURRENTLY HAVE OR ARE CONCERNED ABOUT)
RESPIRATORY
GASTROINTESTINAL
CARDIOVASCULAR
Shortness of breath
Nausea/Vomiting
High blood Pressure
Coughing
Abdominal/Stomach pain
Heart disease/Heart attack
Asthma or Wheezing
Heartburn/Acid Reflex
Congestive Heart Failure
Emphysema
Ulcer Disease
Heart Murmur
Snoring
Belching/Burping
Irregular Heartbeat or
Palpitations
Daytime Sleepiness
Rectal Bleeding
Chest pain or Discomfort
Disturbed Sleep
Hemorrhoids
Ankle or Feet Swelling
Sleep Apnea
Constipation/Diarrhea
Varicose Veins
History of Pneumonia
Gallbladder Disease/Gallstones
Blood Clots or Clotting Disorders
Chronic Bronchitis
Celiac Disease/Gluten Intolerance
COPD
Hernia
GENITOURINARY
MUSCULOSKELETAL
SKIN & HAIR
Difficulty Urinating
Aching Muscles/Joints
Skin Sores/Infections
Urinary Incontinence
Lower Back Pain/Disc Problems
Bruises Easily
Inability to Empty Bladder Fully
Arthritis
Chronic Rashes/
/
Dermatitis
Eczema
Recurrent Urinary Tract Infection
Infertility
Abnormal Menstrual Periods
Enlarged Prostate
ENDOCRINE
OTHER
Diabetes Mellitus
Low Energy Level
Anorexia
High Cholesterol
Bipolar Disorder
Anemia
High Triglycerides
Attention Deficit Disorder (ADD)
Bulimia
Thyroid Disease
Hyperactivity Disorder (ADHD)
Headaches or Migraines
Gout
Depression
Anxiety Disorder or Panic Attacks
Binge Eating
Obsessive-Compulsive Disorder (OCD)
Other serious medical conditions (list types): ________________________________________________
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