Functional Nutrition
Physical activity assessment

Daily Activity Questionnaire and Exercise History Questionnaire

Have you been cleared for exercise? *

How do you monitor your exercise intensity?

General Intensity *
Talk Test *
Perceived Exertion *
Heart Rate *
Are you satisfied with your current exercise program?

If no, explain :

Explain:
What are your motivators for exercise? (Check all that apply)
for other option do you want to explain?
Explain:
What types of aerobic exercise do you prefer? (examples: Walking, hiking, blading, jogging, treadmill, bicycling indoors/outdoors, EFX elliptical, stair climbers, swimming, rowing,water aerobics, aerobics classes, cross country skiing, downhill skiing/snowboarding, snowshoeing, other)
What do you like most about exercising?
Do you have an exercise partner?
Do you enjoy group exercise or classes?
Are you a member of a gym or fitness center?
Are there any obstacles you have to engaging in movement and physical activity?
If yes, what are they?
If yes, do you have control over the circumstances surrounding your obstacles? How can you overcome them?
Are any of your obstacles out of your control? If yes, which ones?
What are some possible solutions around these obstacles? What has worked before?
What is the best time of day for you to exercise?
When do you have the most energy and time?
Are you ready to take action to make your exercise program work for you and your goals?
please explain:
Do you have any goals related to you strength, tone, body composition, or fitness level?
please explain:
Do you experience any pain or breathing problems while exercising?
please explain:
Do you have any joint or musculoskeletal problems that might flare up during exercise?
please explain:
Have you had any injuries while exercising?
please explain:
Have you experienced a loss of muscle tissue or a decline in strength over the last few years?
please explain:
Have you fallen in the past few months?
please explain:
Do you notice any balance problems?
please explain:
Do you have any of the following exercise contraindications? (Check all that apply)
For Other option do you want to explain:
please explain:

Please check the one best response for each activity described below:

SEDENTARY BEHAVIOR (Sitting while watching TV, at computer, driving, talking on the phone, or reading )
ACTIVITIES OF DAILY LIVING ( Bathing, dressing,feeding self, toilet )
Laundry
Housekeeping
Grocery Shopping
Social Activities (Church, temple,family and friends)
Driving
Errands or Light Chores (Post office,drop off a child)

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