Health And Fitness Goal Assessment - Questionnaire
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1Health and Fitness Goal Assessment
This questionnaire will help us to understand your personal fitness goals. It is also a “contract” in which
we as you to make a commitment to three concrete steps towards fitness and health. It is not a legal
contract with us, but rather a personal contract that you make with yourself and with others
concerned with your health. Should you have any questions, feel free to ask. Your responses will be
treated in a confidential manner.
Please indicate your personal health and fitness-related goals: (you may choose more than one)
◊ Lose Weight
◊ Improve Flexibility
◊ Reduce Back Pain
◊ Stop Smoking
◊ Reduce Stress
◊ Improve Diet
◊ Feel Better
◊ Lower Cholesterol
◊ Cardiovascular Fitness
◊ Increase General Fitness
◊ Increase Muscular Size
◊ Increase Strength
◊ Sports specific
◊ Look Better
◊ Injury Rehabilitation
Please tell us more about your exercise patterns and goals:
What health improvements do you need?
What other health improvements do you want?
What are your activity preferences?
What barriers to success do you anticipate?
How will you know you are succeeding?
How would you rate your motivation level to achieve these goals? ◊ Low ◊ Medium
◊ High
How confident are you in your ability to reach these goals?
◊ Very confident
◊ Sort of confident
◊ Not at all confident
Please use the space below to record three concrete commitments that you are willing to make to
your own health goals. For example, you might commit “To arrive, ready for exercise, on Mondays,
Wednesdays and Fridays by 6:30 p.m.” These should be challenging, but also realistic and attainable
commitments. When finished, please sign this form to signify your personal commitment.
Commitment #1: _________________________________________________________________________________
Commitment #2: _________________________________________________________________________________
Commitment #3: _________________________________________________________________________________
Signed: ________________________________________________________________
Date: ___/___/___
Witness:________________________________________________________________
Date: ___/___/___
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Parent category: Medical