New Student History & Lifestyle
City: State: Zip:
Preferred Phone Number: Secondary Phone Number:
Marital Status: SingleIn a Domestic PartnershipMarriedOther
Any Children? YesNo
If Yes, Age(s):
Height: Weight: Weight one year ago:
Are you happy with your current weight? YesNoSomewhat
Do you have any history of disordered eating patterns? YesNo
If yes, please feel free to elaborate a bit:
SECTION II: STUDENT HEALTH
Heart Disease YesNo
Shortness of Breath or Chest Pain YesNo
Inhaler? YesNo (if “yes”, please bring it to every class)
High Blood Pressure YesNo
High Cholesterol Level YesNo
Significant Bone/Joint/Muscle Pain YesNo
Back Pain YesNo
Cigarette Smoking YesNo
Abnormal Resting EKG YesNo
Insulin Dependent? YesNo
Any other? Please explain:
Are you currently taking any medication(s)? YesNo
Allergies: Food Environmental Medical
Describe typical meal choices:
Late night snack
Percentage of food made at home: 90-100%70-90%50-70%0-50%
How many hours a day/week do you spend driving a car?
How many hours do you sit at a desk?
Does your job require you to walk and move often?
How would you describe the amount of time on your cell phone? LittleNormalHigh
Do you sit at a computer and if so for how many hours of your work day?
Please feel free to elaborate:
Average hours of sleep per night: less than 44-66-88-10more than 10
What activities do you like to do to relax?
Stress Levels at Home 12345
Stress Levels at Work 12345
What gets you excited about exercise? Do you feel you are disciplined enough to maintain a fitness route on your own? Do you feel energized or depleted after your normal exercise regimen? EnergizedDepleted
Type of Exercise
Times per week
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Document Name: New Student History & Lifestyle
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