Personal Fitness & Nutrition Development Questionnaire Page 2
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3What activities/exercises do you currently participate in? (Check all that apply)
Running/Walking
Aerobics
Strength Circuit
Biking
Dance
Free Weights
Swimming
Yoga/Pilates
Resistance Training
Outdoor Activities
Martial Arts
Athletics: If so, what______________________________
Recreational Activities
Calisthenics
Other: _________________________________________
Golf
Conditioning
What is your current activity level?
None
Moderate (1-5 hours a week)
Little (Less than one hour a week)
High (Over 5 hrs. a week)
What activities/exercises did you participate in the past? (Check all that apply)
Running/Walking
Aerobics
Strength Circuit
Biking
Dance
Free Weights
Swimming
Yoga/Pilates
Resistance Training
Outdoor Activities
Martial Arts
Athletics: Which Sports______________________________
Recreational Activities
Calisthenics
Other: _________________________________________
Golf
Conditioning
What was your past activity level?
None
Moderate (1-5 hours a week)
Little (Less than one hour a week)
High (Over 5 hrs. a week)
Height: __________ Weight: __________
Have you had any recent weight gain or loss?
Yes
No
If yes, please explain.
List your top 3 nutrition questions or concerns.
Tobacco Use:
Alcohol Use:
I currently smoke
I frequently drink alcohol
I quit smoking less than six months ago
I occasionally drink alcohol
I quit smoking over six months ago
I seldom drink alcohol
I never used tobacco
I never drink alcohol
Do you take any vitamins, minerals, or supplements?
Yes
No
If yes, please explain:
List current medications and reason for taking:
1551 Mayview Road
Upper St. Clair, PA 15241
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