LIFESTYLE - Posh Fitnessposhfitness.com/fitness-forms/Lifestyle-Questionnaire.pdf · Thank you for filling out the Lifestyle Questionnaire. Please save a completed copy for your personal
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LIFESTYLEQUESTIONNAIRE
OtherPlease provide any other notes regarding your health goals: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
Thank you for filling out the Lifestyle Questionnaire. Please save a completed copy for your personal use. You can use this copy to compare your progress with a questionnaire on the final day of the program.
Health Goals1. Describe your major health, nutrition, and/or fitness goals: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
2. What are the two to three biggest barriers to achieving these goals? 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________
3. What are the two to three greatest strengths that will help you to achieve these goals? 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________
4. Please check the box that best describes how ready you are to make changes to your lifestyle to achieve these goals ⎔ Do not believe I need to change ⎔ Would like to change, but don’t think that I can ⎔ Will make changes soon ⎔ Recently started to make changes (past 6 months) ⎔ Would like to intensify changes ⎔ Made changes, but relapsed
5. On a scale of 1-10, how important is this change to you? _______
6. On a scale of 1-10, how confident are you that you will achieve this change? _______
Health Information7. How would you describe your health?⎔ Excellent ⎔ Good ⎔ Fair ⎔ Poor
8. When was the last time you visited your physician? __________
Nutrition History9. Have you ever followed a modified diet to manage a health condition?
⎔ Yes ⎔ No
If yes, please describe: _________________________________
10. Do you follow a specialized diet (low carb, gluten-free, vegan, etc.)⎔ Yes ⎔ No
If yes, please describe the diet and reasons for following: ___________________________________________________
Who purchases and prepares your food? _____________________
Physical Activity11. Are you currently physically active?
⎔ Yes ⎔ No
If yes, please describe: ____ minutes of cardiovascular activity, _____times per week ____ minutes of strength or resistance training, ____times per week ____ minutes of flexibility training, _____times per week
12. Please list your favorite physical activities: ___________________________________________________
Weight History13. What would you like to do with your weight?
⎔ lose ⎔ maintain ⎔ gain
14. What was your lowest weight in the past five years ? _______Your highest? _______
15. What is your current weight? ________________________What is your height? _________________
Health Goals1. What are your one-month, one-year, and five-year health, nutrition, and/or fitness goals: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
2. What are the two to three biggest barriers to achieving these goals? 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________
3. What are the two to three greatest strengths that will help you to achieve these goals? 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________
4. Please check the box that best describes how ready you are to permanently commit to your lifestyle change ⎔ Do not believe I need to commit ⎔ Would like to commit, but don’t think that I can ⎔ Will commit soon ⎔ Recently started to commit (past 6 months) ⎔ Would like to intensify commitment ⎔ Made commitment, but relapsed
5. On a scale of 1-10, how important is this change to you? _______
6. On a scale of 1-10, how confident are you that you will achieve this change? _______
Health Information7. How would you describe your health?⎔ Excellent ⎔ Good ⎔ Fair ⎔ Poor
8. When was the last time you visited your physician? __________
Nutrition History9. Have you ever followed a modified diet to manage a health condition?
⎔ Yes ⎔ No
If yes, please describe: _________________________________
10. Do you follow a specialized diet (low carb, gluten-free, vegan, etc).⎔ Yes ⎔ No
If yes, please describe the diet and reasons for following: ___________________________________________________
Who purchases and prepares your food? _____________________
Physical Activity11. Are you currently physically active?
⎔ Yes ⎔ No
If yes, please describe: ____ minutes of cardiovascular activity, _____times per week ____ minutes of strength or resistance training, ____times per week ____ minutes of flexibility training, _____times per week
12. Please list your favorite physical activities: ___________________________________________________
Weight History13. What would you like to do with your weight?
⎔ lose ⎔ maintain ⎔ gain
14. What was your lowest weight in the past five years ? _______Your highest? _______
15. What is your current weight? ________________________What is your height? _________________
17. Would you recommend this program to a colleague?⎔ Yes ⎔ No
18. What did you like best about this program? ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
19. How can we improve? ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________
Thank you for filling out the final Lifestyle Questionnaire. Please compare this copy to your copy from day one!
Long-term SMARt goals are those specific, measurable, attainable, relevant, and time-bound goals that you hope to have achieved in the next 6 months to one year and beyond. these are the goals that you will make slow and steady progress towards achieving each time you achieve your short-term SMARt goals. the short-term goals are measured in days, weeks, and months.
EXAMPlE: i am going to eat at least seven servings per day of fruits and vegetables by the end of summer.
EXAMPlE: i am going to lose 30 pounds in the next year by exercising at least 20 minutes most days of the week and only eating a dessert once per week.
EXAMPlE: i am going to break the cycle of emotional eating within the next six months by eating every meal at the kitchen table without any distractions.
Now, identify what you think overall will be the 2 biggest barriers to you sustaining your lifestyle change. Describe how you might use your supports and other tools to overcome them.