Lifestyle Questionnaire

CONFIDENTIAL

In order for me to provide you with quality health care, please provide the following information regarding your present state of health and medical history. Please note that all of this information is required for me to make an accurate assessment of your individual needs and to help you achieve the best possible results. The information you provide is completely confidential.

Personal Details
Date *
Date
Name *
Name
Date of Birth *
Date of Birth
Goals & Expectations
1 = very poor, 10 = excellent
1 = very poor, 10 = excellent
1 = not at all, 10 = 100% committed to making changes
1 = no confidence, 10 = extremely confident
What do you hope to get out of this program? *
Days / Weeks / Months / Years
What do you think could stop you from achieving your health goals? *
Medical
If none, enter "n/a"
If none, enter "n/a"
If unsure, enter "unsure"
How would you rate your pelvic floor muscles? *
1 = weak, 5 = strong
Lifestyle Habits
1 = low stress. 10 = highly stressed
Exercise Habits
1 = very poor, 10 = excellent
How often per week
Rate from 1-10. 1 = sitting on the couch and 10 = as hard and fast as possible
Eating Habits
1 = very poor. 10 = excellent.
Breakfast / Mid morning snack / Lunch / Afternoon snack / Evening snack
1 cup = 250ml
Do you eat any of the following once per week or more? *
How often do you eat out per week? *
Breakfast, lunch or dinner
Breakfast / Lunch / Dinner
I.e. Weight watchers, Jenny Craig, etc
For each diet plan listed above
For each diet plan listed above
For each diet plan listed above
For each diet listed above
Mindset Habits
1 = very poor, 10 = excellent
1 = extremely low, 10 = extremely high
1 = extremely low, 10 = extremely high
1 = extremely unlikely, 10 = extremely likely
1 = extremely unlikely, 10 = extremely likely For example: I am intelligent, capable, strong and beautiful
1 = extremely unlikely, 10 = extremely likely
1 = extremely unlikely, 10 = extremely li
Please outline which challenges you may face from 1 to 5
1 = not a challenge for you. 5 = significant challenge for you.