Lifestyle Consultant

Physical Activity Readiness Questionnaire

Name	Date
Male / Female	Occupation
D.O.B	Mobile
Email Address	Dr Practice
	Dr Name

Medical history Have you ever had, or do you suffer from now?
Heart Attack	Cancer	Stroke
Auto immune disorder	Depression	Abnormal ECG
Irregular heart beat	Aneurysm	Angina
Cardiac condition	Tachycardia	Bradycardia
Embolism	Thrombosis	Anaemia
High blood pressure	Low blood pressure	Blood disorder
Pulmonary disorder	Epilepsy	Hernia
Respiratory infection	Pneumonia	Osteoporosis
Diabetes	Asthma	Headaches
High Cholesterol	Allergies	other- illness or disease?

Are you currently taking any prescribed medication? (Please list)

Please state medical condition?

Is there a history of any heart conditions or any other illnesses in your immediate family?

Has your Doctor ever advised you against exercise for any reason?

Please list any surgery, serious injuries or other complaints with dates?

Do you have or have you had any of the following conditions?

Head/Neck injuries	Ankle/Foot injuries	Wrist/Hand injuries
Shoulder injuries	Back injuries	Hip/Pelvis injuries
Arm/Elbow injuries	Knee/Leg injuries	Nerve damage
Other injuries?

Are you currently receiving any kind of physical therapy or under any doctor’s supervision?

How many times have you been prescribed Anti-biotics in your life approx?

Lifestyle Factors

Do you smoke? If yes, how many a day?

Do you drink? If yes, how many units a week?

Are you currently pregnant, planning to have, or have had a baby in the last year?

Are you prepared to devote at least 3 sessions a week to training?

Is the time, duration or frequency of workouts a factor for you?

Do you think your occupation could affect your exercise routine?

Do you feel "Stressed out" in any areas of your life?

Do you get 15-30 minutes a day of direct sunlight?

Do you ever grind your teeth?

Do you feel you get enough sleep?

Are you living in the same time zone you were born in?

Do you get brain fog or have difficulty concentrating on tasks for extended periods?

If you pinch your skin on the back of your hand how many seconds does it take to return to normal?

Press a finger above the ankle for 10 seconds. Does a dimple stay in the skin for longer than 1 or 2 seconds?

Do you ever get headaches? How often?

Do you drink Coffee or Caffeinated drinks? How many a day?

Diet & Nutrition

How much water do you drink daily in Litres not including milk, coffee, tea, sodas or fruit juices?

Do get dark circles or eye bags with sunken eyes?

What is your blood type? O, A, AB or B

Do you know the Rhesus factor? Positive or Negative?

Have you ever crash dieted?

Will you alter your eating habits if advised to do so for improved health?

How many meals a day do you prepare, cook & eat from scratch?

Are you a vegetarian/vegan?

Have you ever had any serious eating disorders?

Do you ever suffer from indigestion, gas, I.B.S, abdominal bloating, cramps or back pain?

Do you take Pro-biotics?

Do you have difficulty digesting meat and/or dairy products?

Do you get tired, sleepy, feel sluggish or lack mental clarity after certain meals?

Do you ever get eczema, psoriasis, acne, blotchy skin patches or rashes?

Have you ever had athlete's foot, Candida, fungal nail growth or discolouration?

Do you eat breakfast? If not how many times a week missed?

What do you eat for breakfast?

Do you eat white refined carbohydrate like white sugar, instant noodles or wheat products?

Do you eat low fat foods & sodas or diet products & artificial sweeteners containing Aspartame?

Do you avoid fats when eating?

What type of fats/oils do you consume?

Do you use normal table salt for cooking & flavouring food?

Do you eat Organic foods? How often?

How often do you go food shopping?

Do you use Microwave ovens? How often?

How would you rate your diet? Good, Bad, Average or don’t know?

On average how many meals do you eat daily?

Do you snack between meals?

Do you get cravings? Sweet (sugar) or Savoury (salt)

Do you ever eat 'Raw' foods?

Are you willing to follow a Detox program if advised to do so?

Do you have allergies or intolerances? (nuts, dairy, wheat, shellfish, pollen, chemical sensitivities, etc)

Do you suffer from excessive mucus production, mucus in stools, nasal/sinus rhinitis, congestion or aching joints?

Do your teeth fit together properly?

Please list any Dental work carried out? Place tick the chart for fillings, caps, crowns or bridge:

Please use this chart to indicate any Dental work you have received it

Left Side

Right Side

#16

#15

#14

#13

#12

#11

#10

Upper

Wisdom

2nd Molar

1st Molar

2nd Bi-cuspid

1st Bi-cuspid

Canine

Lateral Incisor

Central Incisor

Lateral Incisor

Canine

1st Bi-cuspid

2nd Bi-cuspid

1st Molar

2nd Molar

Wisdom

#17

#18

#19

#20

#21

#22

#23

#24

#25

#26

#27

#28

#29

#30

#31

#32

Lower

Wisdom

2nd Molar

1st Molar

2nd Bi-cuspid

1st Bi-cuspid

Canine

Lateral Incisor

Central Incisor

Lateral Incisor

Canine

1st Bi-cuspid

2nd Bi-cuspid

1st Molar

2nd Molar

Wisdom

Have you had Root canal treatment? Please indicate the corresponding tooth/teeth from the chart.

Do you wear dentures or have metal braces?

Activity levels

How do you rate the amount of activity you perform at work?
Very Little
Little
Moderate
Active
Very Active

How do you rate the amount of activity you perform during your leisure time?
Very Little
Little
Moderate
Active
Very Active

Can you rate your average daily energy levels? 1 Low/poor to 5 High/excellent?

Have you ever been diagnosed with chronic fatigue syndrome CFS?

Are there any gym activities that do not interest you? Or that may cause you any discomfort or pain?

Are there any sports or gym activities that you enjoy & would like to incorporate into your training program?

Do you require sport specific training or conditioning?

Which component of training do you prefer or consider you are best physically suited to? (Please tick)
Fast/Explosive Strength Work
Slower/Longer Endurance Events

Goal Setting

How do you rate your current physical condition? (Please tick

Overweight	Underweight	Ideal weight
Well	Unwell
Fit	Unfit
Healthy	Unhealthy

Would it interest you to do certain test periodically? (Please tick)
Strength testing
Muscular Endurance testing
Cardiovascular/Fitness testing: Vo2Max, Bleep test or Chester step test

Do you want to? (Please tick)

Lose weight?	How much?
Gain weight/muscle?	How much?
Stay same weight
What do you want to achieve? (Please tick) Tone up Fat loss/Inch loss Weight loss Increase muscle mass Increase strength/power Improve "core" strength Improve fitness level Improve health and vitality(lifestyle factors) Competition preparation	Improve reaction speed Improve Posture or Corrective exercise Pain relief Therapy/rehabilitation Improved nutritional understanding Complimentary supplement support Work, Lifestyle & Training balance Improved General fitness Improved sex life

On a scale of 1-10 (1 low & 10 high) how important is it to you to reach your personal goals?

Do you have any specific areas of the body you would like to concentrate on? (Please list)

What are your initial goal/s for the first 4 weeks? (Please list)

What will be your goal/s be for 12 weeks? (Please list)

What are your long terms goal/s? (Please list)

Do you think you are? (Please tick)
Confident & Assertive
Shy & Withdrawn
A bith of both

Do you suffer from any Fears, Phobias or Anxieties?

Would you use clinical Hypnotism or Emotional Freedom Technique (E.F.T) to help achieve your goals?

How best do you learn? Visual, Kinestetic or Auditory?

Do smells invoke reactions, memories or emotions with you?

What is your Divine faith or inspiration?

Are you more receptive to Authoritive or Permissive commands?

What is your favourite colour?

What is your favourite smell?

What is your favourite taste?

What is your favourite sound?

What do you like the feel or touch of?

Have you ever hired a Personal Trainer/Strength & Conditioning coach before?

Where did you hear about our services?

Lifestyle Consultant

Physical Activity Readiness Questionnaire

Medical history

Lifestyle Factors

Diet & Nutrition

Activity levels

Goal Setting