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Exercise Health and Lifestyle

In: Science

Submitted By azzyg123
Words 294
Pages 2
I am holding a “Healthy Lifestyle Day” at a leisure centre where I am a trainee lifestyle consultant. I have created this questionnaire for a friend or family member to complete. This questionnaire will help me create a training programme for them to better their physical levels.
Personal Details:
Date of Birth:

Physical Activity:
Do you exercise regularly? (Times in one week)
How intense do you train? (Tick a box) Low Moderate High
What is the duration of your training? (Tick a box) 1-10mins 11-30mins 31mins and above
What is your favourite activity?
Running Football Cricket Softball Rugby American Football Basketball

Boxing Hockey Any other? (Please state)

How often do you eat junk food? (how often with 0 being never and 10 being all the time)

0 1 2 3 4 5 6 7 8 9 10
What is your daily intake of calories?
How often do you drink water?
Do you eat your five-a-day?
Do you record your daily intake of carbohydrates, vitamins and minerals? If so what is your daily intake?
What are the things that cause you stress? How intense is your stress? Low Moderate High
Does your stress cause you to focus or falter?
How do you control your stress?
Does stress affect your diet?
Alchohol and Smoking:
How often do you drink?
How much do smoke in one sitting?
Do these affect your personal life?
Are you a binge drinker?
Why do you drink and/or smoke? (E.g. peer pressure)
How much do you spend on them?
How often do you smoke? (per day)

1-3 4-7 8-10 11-14 15 and higher
Do you consider smoking and/or drinking to be a stress...

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