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Lifestyle Questionnaire Part 1

Name………………………………………………………………………..

Address…………………………………………………………………………………………………

Telephone ……………………………. Email ……………………………………………………..

Please take a few moments to answer the following questions. Your answers will be used todetermine if you have any health issues or concerns that may prevent you from participating in alifestyle change program without a physician's approval. Please take your time and think abouteach question before you answer.

1. Do you have a history or have you ever been diagnosed with high blood pressure (systolic BPequal to or higher than 140, or diastolic BP equal to or higher than 90 mmHG)

Yes/ No

2. Have you ever had coronary angioplasty or cardiac surgery?

Yes/ No

3. Do you have a history of or have you ever experienced: heart disease, heart attack, angina?

 Yes/ No

4. Have you been diagnosed with a heart murmur?

Yes/ No

5. Have you ever had a stroke?

Yes/ No

6. Do you have a history of or have you ever been diagnosed with diabetes?

Yes/ No

7. Do you have a history of or have you ever been diagnosed with kidney disease?

Yes/ No

8. Do you have a history of or have you ever been diagnosed with thyroid or other metabolicdisorders?

Yes/ No

9. Have you been diagnosed with asthma?

Yes/ No

10. Have you been diagnosed with chronic bronchitis?

Yes/ No

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11. Have you been diagnosed with emphysema or chronic obstructive pulmonary disease(COPD)?

Yes/ No

12. Have you been told by your physician that you have a condition that will limit or prevent youfrom exercising and participating in lifestyle improvement programs?

Yes/ No

13. Do you currently have any of the following: ankle swelling, chest pain, dizziness/fainting,rapid heartbeats or palpitations, shortness of breath, unexplained fatigue?

Yes/ No

14. Is there any aspect of your health that you are concerned about and would feel more

comfortable talking with your physician about before starting a new lifestyle change/exerciseprogram?

Yes/ No

15. Do you currently have a smoking habit?

Yes/ No

16. Have you had any orthopaedic (bone/joint) problems in the past 6 months?

Yes/ No

17. Are you a Female who is 55 years of age or older?

Yes/ No

18. Are you a Male who is 45 years of age or older?

Yes/ No

19. Are you pregnant?

Yes/ No

20. Have you had surgery in the past six months?

Yes/ No

Thank you for answering the questions in this survey. If you answered YES to any of the abovequestions, you need to consult your doctor and receive guidance from them as to any limitationthey feel you should have in making a lifestyle change.

I dec lare that a l l o f the above in fo rmat ion i s , to the bes t o f my be l ie f , t rue and

accu r a t e .

Signature........................................................................................

Date......................................................