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Exercise History Questionnaire
Patient Name
Date
Not Set
1. Have you been cleared for exercise?
YesNo
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
x per week for
minutes
Activity 2
x per week for
minutes
Strength/Resistance exercise: (e.g., resistance machines, kettle bell, pilates, weightlifting)
Activity 1
x per week for
minutes
Activity 2
x per week for
minutes
Flexibility/Stretching exercise: (e.g., yoga, pilates, matwork, stretches)
Activity 1
x per week for
minutes
Activity 2
x per week for
minutes
Balance exercise: (e.g., tai chi, qi gong, bosu ball, dancing))
Activity 1
x per week for
minutes
Activity 2
x per week for
minutes
3. How do you monitor your exercise intensity?
General Intensity
LightModerateVigorous/hard
Talk Test
Able to talk and/or singAble to talk but not singDifficulty talking
Perceived Exertion
< 3 (10 point scale)3–4 (10 point scale)≥ 5 (10 point scale)
Heart Rate*
< 64% HRmax64–76% HRmax>76% HRmax
4. Are you satisfied with your current exercise program?
YesNo
If no, explain
5. What are your motivators for exercise? (Check all that apply)
Prevent cardiac disease and strokeReduce blood pressureControl blood glucosePrevent bone lossIncrease energyIncrease self esteemImprove moodDecrease stressImprove sleepWeight reductionIncrease mental alertnessBetter enduranceIncrease interest in sexOther
If other
6. What types of aerobic exercise do you prefer? (Circle all that apply)
Walkinghikingbladingjoggingtreadmillbicycling indoors/outdoorsEFX ellipticalstair climbersswimmingrowingwater aerobicsaerobics classescross country skiingdownhill skiing/snowboardingsnowshoeingother
If other
7. What do you like most about exercising?
8. Do you have an exercise partner?
YesNo
9. Do you enjoy group exercise or classes?
YesNo
10. Are you a member of a gym or fitness center?
YesNo
11. Are there any obstacles you have to engaging in movement and physical activity?
YesNo
a. If yes, what are they?
b. If yes, do you have control over the circumstances surrounding your obstacles? How can you overcome them?
c. Are any of your obstacles out of your control? If yes, which ones?
d. 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?
YesNo
15. Do you have any goals related to you strength, tone, body composition, or fitness level?
YesNo
If yes, explain:
16. Do you experience any pain or breathing problems while exercising?
YesNo
If yes, explain:
17. Do you have any joint or musculoskeletal problems that might flare up during exercise?
YesNo
If yes, explain:
18. Have you had any injuries while exercising?
YesNo
If yes, explain:
19. Have you experienced a loss of muscle tissue or a decline in strength over the last few years?
YesNo
20. Have you fallen in the past few months?
YesNo
21. Do you notice any balance problems?
YesNo
If yes, explain:
22. Do you have any of the following exercise contraindications? (Check all that apply)
Acute systemic infection (i.e., fever, body aches, swollen lymph nodes, etc.)ArrhythmiasRecent heart attackSevere congestive heart failureUncontrolled angina/chest painOther
If other
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