Health & Fitness Questionnaire

E-mail Address:*
Name (First & Last)*
Date*
On average I exercise for 30 minutes or more*
In the past I exercised*	Never Not often enough On a regular basis I played competitive sports I was active all the time
Exercise is difficult because (check all that apply)*	I am not sure what to do Kids, work, kids, cook dinner...... I am not very motivated I find it...hold on American Idol is on I just dont have enough time I find the gym intimidating
On an average day I drink water (1 glass = 8 oz)*	Never, I am a camel 1-2 glasses per day 3-5 glasses per day 5+ glasses per day I prefer diet pop
I am a regular user of the following (please check all that apply):*	Alcohol Nicotine Coffee Fast foods Processed foods (things with ingredients you cant pronounce)
My eating habits consist of (check all that apply)*	Thank God for microwave dinners I am vegan If this is Tuesday I must be ordering pizza Meat, meat, could you please pass the meat Lots of fresh fruit, veggies, nuts and fish I eat well most the time but do have my weaknesses Vegetables dont come frozen? Whatever my mom cooks
In the last five years I have gone on a diet or used the following:*	I have tried to diet almost every year Atkins Diet SouthBeach diet Weight Watchers I have not tried to diet
On average I get enough sleep each night:*	Never Not often enough Sometimes Always
In the past I have (please check all that apply):*	purchased a gym membership joined a sports team gone to a yoga and/or pilates class attended aerobics used the services of a personal trainer participated in an organised run
When I go shopping for groceries (please check all that apply):*	I buy a variety of foods Know how to read a food label Purchase mostly brown rice, bread & pasta Shop according to the Canada Food Guide Buy whatever the 7-11 has on special Buy fresh fruit & veggies every 3-4 days
On average I find my everyday life to be:*	Very fullfilling Somewhat stressful A bit stressed, but nothing I cant handle Cant say, its passing me by Everyday I am putting out fires and its driving me crazy
In general, would you say your current physical fitness is:*	Very good Good Average Poor Very poor


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