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?

Please state medical condition?

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

Lifestyle Factors


Diet & Nutrition

Please use this chart to indicate any Dental work you have received it
Left Side
Right Side
  #16 #15 #14 #13 #12 #11 #10 #9 #8 #7 #6 #5 #4 #3 #2 #1
Upper Wisdom 2nd Molar 1st Molar 2nd Bi-cuspid 1st Bi-cuspid Canine Lateral Incisor Central 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 Central Incisor Lateral Incisor Canine 1st Bi-cuspid 2nd Bi-cuspid 1st Molar 2nd Molar Wisdom
 

Activity levels






How do you rate the amount of activity you perform during your leisure time?





Which component of training do you prefer or consider you are best physically suited to? (Please tick)
Strength Work 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)


Do you want to? (Please tick)
Gain weight/muscle?
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

Do you think you are? (Please tick)