Mind Your Body Assessment Questionnaire Please complete this form before joining the Mind Your Body Program. All information received within this package will be treated as strictly confidential Please Tell Me About Yourself SKLPT MIND YOUR BODY ASSESSMENT QUESTIONNAIREFirst Name Last Name Date of Birth Home Phone Work Phone Email Address Occupation Fitness History and GoalsDo you consider yourself to be active? Yes NoHow often do you exercise a week? 0 1 2 3 4 5 6 7What exercise(s) do you enjoy? Walking Jogging Running Swimming Tennis Squash Weight Training Cycling Group Exercise Indoor Cycling StairmasterOther exercise(s) you enjoy? What are your main fitness goals? Improve body composition Build strength Increase muscle mass Improve mobility Improve endurance & Conditioning Improve athletic performance Any injuries or reasons why you can’t exercise regularly? LifestyleRate your stress on a daily basis: Low Moderate HighList your you No 1. biggest sources of stress List your you No 2. biggest sources of stress List your you No 3. biggest sources of stress How much sleep do you average each night? Do you smoke? Yes NoAlcohol Consumption? None Mild Moderate FrequentNutritional HabitsWhat types of food do you crave? When you crave foods do you crave mainly salty foods, fats, or sugar? How many times a day do you usually eat? How many times a week do you dine out Do you eat breakfast? Yes NoHow much water do you consume on a daily basis? Do you do your own cooking? Yes NoEmotional/Mental Well-BeingI can realistically assess my limitations and cope effectively with stress Never Sometimes Often AlwaysI have a sense of control in my life and I am able to adapt to change Never Sometimes Often AlwaysI have a healthy inner narrative and practice self-compassion Never Sometimes Often AlwaysI often feel energized, focused, and inspired throughout the day Never Sometimes Often AlwaysWhen I face challenges I can bounce back quickly. Never Sometimes Often AlwaysSpiritual Well-BeingDo you feel a sense of passion and purpose in your life? Do you have specific goals in your personal and professional life? Does your job utilize your greatest talents? Is your life enjoyable and fulfilling? Do you use meditation, contemplation, or a mindfulness practice to better understand your thoughts and feelings? Health HistoryAre you currently taking any medications? Yes NoIf you circled YES, please list the medication: And please list the condition: If you circled YES, please list the medication: And please list the condition: Does this medication affect your ability to exercise or hinder your fitness goals? PAR-Q & YOUHas your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Yes NoDo you feel pain in your chest when you do physical activity? Yes NoIn the past month, have you had chest pain when you were not doing physical activity? Yes NoDo you lose your balance because of dizziness or do you ever lose consciousness? Yes NoDo you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? Yes NoIs your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? Yes NoDo you know of any other reason why you should not do physical activity? Yes NoRealistically, how often a week would you like to exercise? What are the best days of the week for you to commit to your exercise program? Monday Tuesday Wednesday Thursday Friday Saturday Sunday I UNDERSTAND AND ACKNOWLEDGE THAT participation in physical activity may involve increased risk of personal injury. I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment, is a potentially hazardous activity. I also understand and accept that fitness activities involve risk of injury, and that I am voluntarily participating in these activities, and using equipment with knowledge of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury.Submit Form
