Health and Fitness Goals

Health and Fitness Goals

This questionnaire will help us to understand your personal fitness goals, motivation level, and exercise experiences. It is also a commitment to three concrete steps towards fitness and health. Should you have any questions, feel free to ask. Your responses will be treated in a confidential manner.

Today’s Date: ____/____/____ Client’s Printed Name: ______

Please indicate your personal health and fitness-related goals:

(Choose all that apply)

[ ] Lose Weight [ ] Improve Flexibility [ ] Improve Muscular Balance

[ ] Stop Smoking [ ] Reduce Stress [ ] Aerobic Fitness

[ ] Feel Better [ ] Lower my cholesterol [ ] Muscular Strength

[ ] General Fitness [ ] Muscular Size [ ] Injury Rehab

[ ] Sports Specific [ ] Look Better [ ] Other: ______

-if so which sport(s): ______

Please tell us more about your exercise patterns and goals: What is your exercise history?

______

What health improvements do you need or want?

______

What are your preferences for a cardiovascular and muscular strengthening activity?

______

What barriers do you anticipate on your journey to regular bouts of physical activity? (arthritis, previous sports injuries, medication restrictions)

______

How do you know when you’re succeeding?

______

What is your previous fitness experience (positive and negative)?

______

What would you consider to be your current level of Motivation?

High Medium Low

What do you consider to be your current level of Confidence?

High Medium Low

Please use the space below to record three concrete commitments that you are willing to make to your own health goals. For example you might commit “To arrive, ready to exercise, on Mondays, Wednesdays, and Fridays by 6:30pm”. These should be challenging but also realistic and attainable commitments. When finished, please sign this form to signify your personal commitment.

Commitment #1 (long-term): ______

______

Commitment #2 (short-term): ______

______

Commitment #3 (short-term): ______

______

Client’s Printed Name: ______

Client Signature: ______Date: ______

Witnessed By: ______Date: ______