Medical/health Status Questionnaire (Page 4 of 4) in pdf

Medical/health Status Questionnaire Page 4

½ pint of beer

How many units of alcohol do you

1 glass of wine

consume per week: ______

1 pub measure of spirits (Gin,

(see Alcohol Units Chart)

Vodka etc.)

1 can of beer

1.5

1 bottle of strong lager

2.5

1 can of strong lager

1 bottle of wine

1 litre bottle of wine

1 bottle of fortified wine (port,

sherry etc.)

1 bottle of spirits

Dietary Habits. Please Select All That Apply.

□

I seldom consume red or high-fat meats.

I eat at least 5 servings of fruits/vegetables per

day.

□

I pursue a low-fat diet.

I almost always eat a full, healthy breakfast.

□

My diet includes many high-fiber foods.

I rarely eat high-sugar or high-fat desserts.

Other

Please Indicate Any Other Medical Conditions or Activity Restrictions That You May Have. It is

important that this information be as accurate and complete as possible

□

Is any of this information critical to understanding your readiness for exercise? Are there any other

restrictions on activity that we should know about?

Thank you for taking the time to complete this questionnaire!

Medical/health Status Questionnaire Page 4