The answers you provide in this questionnaire will be kept private and will only be used to address your personal fitness goals with OneLife Health & Fitness.

Personal Information



Health

Do you use tobacco? (smoking or chewing)
NoYes

Do you have any health concerns that could hinder you from a dietary or exercise standpoint such as heart conditions, asthma, high blood pressure, diabetes, etc.?
NoYes

Do you regularly take medications?
NoYes

Do you regularly take any vitamins or supplements?
NoYes

Do you suffer from any type of chronic pain such as herniated discs, nerve damage, shoulder or back pain, etc.?
NoYes

Have you had any injuries or surgeries that prohibit or limit any movements?
NoYes

How many times in a year are you sick?
NoneRarelySometimesOftenRegularly

Nutrition

Do you have any food or drink related cravings?
NoYes

If you crave anything below, check all that apply...
NoneSugarCaffeineAlcoholNicotineBreads/CarbohydratesSalty Foods

If you have cravings when do they kick in?
NoneMorningMid-MorningLunchAfter LunchEveningAfter Dinner

Do you get tired or energetic after eating a meal?
TiredEnergeticNeitherI Don't Know

What percentage of your meals are prepared at home?
None10%20%30%40%50%60%70%80%90%100%

When you eat out where do the meals come from?
Drive-ThruRestaurantGas StationGrocery Deli/Hot Bar

How many servings of vegetables do you eat in a day? (fist full is 1 serving)
None1-23-45-67-89-10

If you eat vegetables what type are they?
FreshFrozenCannedFrom Restaurant/Drive-Thru

How many cups of water do you drink in a day? (1 bottle is roughly 2 cups)
None0-12-34-56-78-910-12

How many cups of caffeinated coffee do you drink in a day?
None0-12-34-56-78-10

How many sodas do you drink in a day?
None0-12-34-56-78-10

How many energy drinks do you drink in a day?
None0-12-34-56-78-10

How many cups of caffeinated tea do you drink in a day?
None0-12-34-56-78-10

Sleep Quality

How would you rate your sleep quality? (1 being terrible and 10 being great)
12345678910

How rested do you feel when you wake up? (1 being terrible and 10 being great)
12345678910

How many hours of sleep do you get, on average, in a night?
1-34-67-99+

Do you get to sleep at the same time most nights?
YesNo

Do you wake up at the same time most mornings?
YesNo

Do you wake up throughout the night? If so, how many times?
None1-23-45-66+

Can you identify with any of the following as the reason for waking up throughout the night?
PainStressHungerthirstyUsing the restroomFeeling SickHot FlashesOther

Do you have trouble falling asleep?
NoYes

Do you have trouble waking up in the morning?
NoYes

Exercise & Movement

Please check any of the sports you played up until adulthood either on a team or recreationally.
SoccerBaseballFootballGolfCheerleadingTrack & FieldHeavy Weight LiftingCyclingRunningBasketballInterval TrainingEndurance Training

Please check any of the activities you’re currently involved in either on a team or recreationally.
SoccerBaseballFootballGolfCheerleadingTrack & FieldHeavy Weight LiftingCyclingRunningBasketballInterval TrainingEndurance Training

Have you ever participated in group exercise?
NoYes

Do you feel energetic or tired after exercising?
EnergeticTiredNeither

Do you exercise at the same time of day, meaning is it structured?
NoYes

How many times a week do you exercise?
None1-23-45-67-8

Stress Management

Does stress affect your every day life?
NoYes

How would you rate your stress level? (1 being lowest and 10 being highest)
12345678910

How does stress affect your every day life? (check all that apply)
Work RelatedFamily DynamicsAnxietyLife in GeneralWeight LossBad HealthFinancesOther

How do you handle stress most of the time? (check all that apply)
Drinking AlcoholDrinkin TobaccoExercisingEatingAngerDepressionMeditationPrayerOther

Are you able to take time aside for the things you enjoy?
NoYes

What would you identify as the primary stress factor in your life?

Is there any additional information about anything above that you feel we need to know?