Body Science - Questionnaire

*** Please print and fill-out this form. ***

HEALTH & FITNESS QUESTIONNAIRE Date:___________
	Check program emphasis:	Health Programs: __Health Reclamation __Health and Fitness Foundation __Weight Loss __Hourly Consult				Athletic Programs: __Sports Foundation or Base Phase __Pre-season __Race Preparation __Training Schedules/advising __Hourly Consult
*Personal Information*
	Name:__________________________________ Birth date:______________________________ Day phone: _____________________________ e-mail:________________________________			Gender: M F Age:_______________________________ Evening phone:_______________________ Cell phone:_______________________ Fax:_______________________________
Address:____________________________________________________________________ Street or P.O. Box _____________________________________________________________________________________________________________ City State zip
	Occupation:__________________________________ Marital Status:________________________________ Children names and ages:________________________ ___________________________________________				Hours worked per week:___________ ______________________________ ______________________________
*Health Information*
	Height:_______________________________ Body Fat %:___________________________ Date of test:___________________________ Lowest adult weight (maintained at least 6 months): _____________________________ Blood Pressure:________________________ Hemoglobin: __________________________ Hematocrit:____________________________		Current Weight:________________________ Method used:__________________________ Weight at testing:_______________________ Name & phone of primary care physician______________________________ Date taken:____________________________ Date taken:____________________________
Describe Any Current Health Issues:_______________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

*Health History*
	Family History	Maternal			Paternal				Self
	Heart Disease
	Hypertension
	Cancer (type)
	Diabetes (type)
	Arthritis
	Depression
	Migraine
	Obesity
	Stroke
	Asthma
	Allergies (type)
	Other (specify)
	Other (specify)
	Other (specify)
If adopted or family history is unknown check here ________ Describe relevant family or personal health history not included above: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Indicate the frequency with: 0 = never 1 = rarely (more than once in 6 months) 2 = sometimes (at least once a month) 3 = often or regularly (at least once a week) 4 = constantly
	_____insomnia _____muscle or joint pain _____migraine headache _____stomach aches _____job stress		_____diarrhea _____muscle cramps _____fatigue _____tension headache _____depression					_____constipation _____colds/flu _____crave sweets _____personal stress
List all medications you take (perscription and over the counter): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ List all vitamin, mineral, food and herbal supplements you take (include amounts): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ List all allergies or any food intolerance: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Are you following a special diet? If so, which? Please describe. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ *Fitness* Describe current exercise status (athletes are encouraged to provide 8 weeks of training logs): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Describe athletic/exercise history: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Do you have a history of injury, anemia, stress fracture or joint surgery? If yes, describe: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Do you stretch regularly, practice relaxation techniques or do hatha yoga? Please describe: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ *Females*
	Are you menstruating?			Y		N	cycle length:________
	Do you take birth control pills?			Y		N
	Do you experience PMS symptoms?			Y		N
	Do you get severe cramps?			Y		N
	My periods are			heavy		medium	light
	Are you menopausal?			Y		N
	If yes, circle any symptoms:			hot flashes		dry skin	sleep disturbances			mood swings
	Post menopause?			Y		N
	If yes, hormone therapy?			Y		N	Which?__________
*Athletes* Sport and specialty: ____________________________________________________________ ____________________________________________________________________________ General athletic goals:___________________________________________________________ ____________________________________________________________________________ Goal events in the next year:______________________________________________________ ____________________________________________________________________________ What is your PR in your event? Include year and age: ____________________________________________________________________________
	Resting heart rate:____________ VO2 max:__________________ Best racing weight:____________ Do you strength train? Y N Do you use or own a heart rate monitor?					Maximum Heart rate:____________ Lacatate Threshold:_____________ Do you belong to a gym? Y N If yes, how often?______________ Y N
Do you experience lingering fatigue or difficulty recovering from work-outs? Y N Do you experience muscle cramps during exercise or races? Y N If yes, please describe: ____________________________________________________________________________ Do you eat or drink during long (2+ hours) training sessions? Y N If yes, what and when? ____________________________________________________________________________ ____________________________________________________________________________ Have you ever had overtraining syndrome or chronic fatigue? Which and when? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Is there a specific topic(s) you would like me to address? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________