Intake Form | Mysite

Health and Lifestyle Questionnaire

First name

Last name

Phone

Address

How would you rate your physical health, with 0 being poor and 10 being the best?

Do you currently participate in any exercise activities? If so, what type of exercise do you do?

How many days a week do you exercise? How many minutes a day do you exercise for?

Do you exercise at home or at the gym? If at home, what equipment do you have?

Do you currently follow any special diet? If so, what diet are you following?

How many days a week or month do you eat out at a restaurant?

What beverages do you consume other than water?

How often do you consume alcohol? How many alcoholic beverages do you consume at a time?

How would you rate your mental health, 0 being the best and 10 being the worst?

How would you rate your average stress level? 0 being no stress and 5 being the highest.

What do you do to manage your stress?

How many hours of sleep do you get at night?

Do you use any tobacco products?

What is your current occupation? Are you required to sit for long periods of time at work?

Have you ever been diagnosed with any chronic medical conditions? If yes what are they?

Please list any past or current musculoskeletal injuries:

Have you been cleared by a medical professional to participate in exercise?

What brought you to FUEL?