ASSESSMENT DATE:

___/___/___

All questions documented in this questionnaire are strictly

confidential and will become part of your consultative record.

Name (Last, First, M.I.): M F DOB: ___/___/___

Marital status: Single Partnered Married Separated Divorced Widowed
Height: ' " Weight: lbs Date of last physical exam: ___/___/___

1. What is your main motivation for entering this program? ________________________________

_________________________________________________________________________________

_________________________________________________________________________________

__ _______________________________________________________________________________

__ ______________________________________________________________________________

2. Which of the following best describes your current exercise routine? (select one)
Little to no exercise
Light exercise - 1 to 3 days a week
Moderate exercise - 3 to 5 days a week
Heavy exercise - 6 to 7 days a week
Very heavy exercise - twice a day OR heavy workouts

3. What is your age? (select one)

35 years or younger
36 to 49
50 years or older

4. What is your waist circumference? (select one)

Measure at your navel/belly button
Less than 80 cm (31 inches)
Less than or equal to 89 cm (31 - 35 inches)
Equal to or greater than 90 cm (35 inches or greater)

5. Which of the following best describes your current lifestyle? (select one)
I exercise regularly AND I have a physically demanding job/occupation
I exercise regularly OR I have a physically demanding job/occupation
I do not exercise regularly AND I have a sedentary job/occupation

(CONTINUED ON NEXT PAGE)

Health Assessment Questionnaire – Initial Consultation Page 1 of 7

6. Which family member(s) have a challenge in maintaining normal blood glucose levels? (select all that
apply)
Mother Other:
Father None
Both Parents

7. How manty cigarettes do you smoke per day? (select one)

1 to 3 8 or more
3 to 5 None
5 to 7

8. How often do you drink alcohol? (select one)

Daily Seldom
Social drinker Not at all

9. How many aerated drinks do you consume per day? (select one)
0 2
1 3 or more

10. I engage in physical movement (i.e., walking, pacing, or standing) for at least 5 minutes: (select one)
After every 30 minutes After every 90 minutes
After every 60 minutes After more than 90 minutes at a time

11. How many minutes of non-exercise activities (i.e. standing, pacing, easy gardening work,
fidgeting) do you accumulate during a complete day? (select one)
Less than 40 min 80 - 119 min
40 - 79 min 120 min or more

12. Please indicate how many days (0-7) and how much time per day you typically engage in
vigorous physical activities each week? (Heavy lifting, aerobics, fast bicycling):

Days per week: Duration per day:

(CONTINUED ON NEXT PAGE)

Health Assessment Questionnaire – Initial Consultation Page 2 of 7

Use the scale below to indicate how much you agree with the following statements (Questions 13-18):

13. I am confident that I can overcome barriers and challenges with regard to exercise if I try hard
enough. (select one)
Strongly disagree Somewhat agree
Disagree Agree
Somewhat disagree Strongly agree

14. I am confident that I can find the means and ways to exercise and be physically active. (select one)
Strongly disagree Somewhat agree
Disagree Agree
Somewhat disagree Strongly agree

15. I am confident that it's easy for me to accomplish my activity and exercise goal. (select one)
Strongly disagree Somewhat agree
Disagree Agree
Somewhat disagree Strongly agree

16. I am confident that I could exercise even if I have no access to a gym or training facility (select one)
Strongly disagree Somewhat agree
Disagree Agree
Somewhat disagree Strongly agree

17. When something prevents me from participating in physical activity, I am confident that I can
usually find several alternative ways to be active. (select one)
Strongly disagree Somewhat agree
Disagree Agree
Somewhat disagree Strongly agree
18. I am confident that I can participate in physical activity even if I am tired. (select one)
Strongly disagree Somewhat agree
Disagree Agree
Somewhat disagree Strongly agree

(CONTINUED ON NEXT PAGE)

Health Assessment Questionnaire – Initial Consultation Page 3 of 7

Use the scale below to indicate how confident you are with the following statements (Questions 19-28):

19. I can resist eating when there are many different kinds of food available. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

20. I can resist eating even when high calorie foods are available. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

21. I can resist eating even when I have to say "no" to others. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

22. I can resist eating even when I don't feel good. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

23. I can resist eating when I am doing other things like reading or watching TV. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

24. I can resist eating just before going to bed. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

(CONTINUED ON NEXT PAGE)

Health Assessment Questionnaire – Initial Consultation Page 4 of 7

25. I can resist eating when I am sad or down or have experienced failure. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

26. I can resist eating when I feel happy. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

27. I can resist eating on the weekends or when I’m in a social setting. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

28. I can resist eating when I am angry or irritable. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

29. I can resist eating when I feel physically run down. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

30. I can resist eating when I feel nervous or uncomfortable. (circle one)

1 2 3 4 5 6 7 8 9 10
Not very
Very
confident
confident

(CONTINUED ON NEXT PAGE)

Health Assessment Questionnaire – Initial Consultation Page 5 of 7

31. When do you typically eat your largest meal? (select one)
Before 3pm
After 3pm

32. Do you have breakfast regularly? (select one)

Yes
No

33. During the last four weeks, how often have you slept seven or more hours per night? (select one)
Not at all Twice a week
Once a week Three or more times a week

34. During the last four weeks, how often have you been restless while sleeping? (select one)
Not at all Twice a week
Once a week Three or more times a week

35. During the last four weeks, how often have you been sleepy when driving or reading? (select one)
Not at all Twice a week
Once a week Three or more times a week

36. During the last four weeks, how would you rate your overall quality of sleep? (select one)
Very good Fairly bad
Fairly good Very bad

37. In the last month, how often were you upset because something happened unexpectedly? (select
one)
Never Fairly often
Almost never Very often
Sometimes

38. In the last month, how often did you feel unable to control the important things in your life? (select
one)
Never Fairly often
Almost never Very often
Sometimes

39. In the last month, how often did you feel nervous and stressed? (select one)
Never Fairly often
Almost never Very often
Sometimes

(CONTINUED ON NEXT PAGE)

Health Assessment Questionnaire – Initial Consultation Page 6 of 7

40. In the last month, how often did you feel confident in your ability to handle your personal
problems? (select one)
Never Fairly often
Almost never Very often
Sometimes

41. In the last month, how often did you feel that things were going your way? (select one)
Never Fairly often
Almost never Very often
Sometimes

42. In the last month, how often did you discover you were unable to cope with everything you had to
do? (select one)
Never Fairly often
Almost never Very often
Sometimes

43. In the last month, how often were you able to control irritations in your life? (select one)
Never Fairly often
Almost never Very often
Sometimes

44. In the last month, how often did you feel you had things under control? (select one)
Never Fairly often
Almost never Very often
Sometimes

45. In the last month, how often did you feel angry because of things were outside of your control?
(select one)
Never Fairly often
Almost never Very often
Sometimes

46. In the last month, how often did you feel you had too many problems to overcome? (select one)
Never Fairly often
Almost never Very often
Sometimes

(END QUESTIONNAIRE)

Reviewed by: _____________________________________

Health Assessment Questionnaire – Initial Consultation Page 7 of 7