Exercise History Questionnaire
Full Name
Date
1. Have you been cleared for exercise?
Yes
No
2. What are you doing on a regular basis that gets you moving and gets your heart rate up? Cardio/Aerobic Exercise: (e.g., walking, jogging, running, dancing)
Activity 1
Times per week
Minutes
Activity 2
Times per week
Minutes
Strength/Resistance Exercise: (e.g., resistance machines, kettlebell, Pilates, weightlifting)
Activity 1
Times per week
Minutes
Activity 2
Times per week
Minutes
Flexibility/Stretching Exercise: (e.g., yoga, Pilates, mat work, stretches)
Activity 1
Times per week for
Minutes
Activity 1
Times per week for
Minutes
Balance Exercise: (e.g., tai chi, qigong, Bosu® ball, dancing)
Activity 1
Times per week
Minutes
Activity 2
Times per week
Minutes
3. How do you monitor your exercise intensity?
General Intensity ⋅ Light ⋅ Moderate ⋅ Vigorous/hard
Talk Test ⋅ Able to talk and sing ⋅ Can talk but not sing ⋅ Difficulty talking
Perceived Exertion ⋅ Less than 3 (out of 10) ⋅ Between 3-4 (out of 10) ⋅ 5 or more (out of 10)
Heart Rate (HR)* ⋅ Under 64% of maximum ⋅ 64-76% of maximum ⋅ Over 76% of maximum
4. Are you satisfied with your current exercise program?
Yes
No
If no, explain
5. What are your motivators for exercise? (Check all that apply)
Prevent heart disease
Reduce blood pressure
Control blood sugar
Prevent bone loss
Increase energy
Increase self-esteem
Improve mood
Decrease stress
Improve sleep
Weight reduction
Increase mental alertness
Better endurance
Increase interest in sex
Others:
6. What types of aerobic exercise do you prefer? (Check all that apply)
Walking
Hiking
Rollerblading
Jogging
Treadmill
Bicycling
Elliptical
Stair climber
Swimming
Rowing
Water aerobics
Aerobics classes
Cross-country skiing
Downhill skiing
Snowboarding
Snowshoeing
Other: (write-in)
7. What do you like most about exercising?
8. Do you have an exercise partner?
Yes
No
9. Do you enjoy group exercise or classes?
Yes
No
10. Are you a member of a gym or fitness center?
Yes
No
11. Are there any obstacles you have to engaging in movement and physical activity?
Yes
No
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?
12. What is the best time of day for you to exercise?
13. When do you have the most energy and time?
14. Are you ready to take action to make your exercise program work for you and your goals?
Yes
No
15. Do you have any goals related to your strength, tone, body composition, or fitness level?
Yes
No
16. Do you experience any pain or breathing problems while exercising?
Yes
No
If yes, explain
17. Do you have any joint or musculoskeletal problems that might flare up during exercise?
Yes
No
If yes, explain:
18. Have you had any injuries while exercising?
Yes
No
If yes, explain:
19. Have you experienced a loss of muscle tissue or a decline in strength the last few years?
Yes
No
20. Have you fallen in the past few months?
Yes
No
21. Do you notice any balance problems?
Yes
No
If yes, explain:
22. Do you have any conditions that would make exercise inadvisable? (Check all that apply)
Acute systemic infection (i.e., fever, body aches, swollen lymph nodes, etc.)
Arrhythmias (heartbeat too fast or slow)
Recent heart attack
Severe congestive heart failure
Uncontrolled angina (chest discomfort or pain)
Others: