Health and Wellness Questionnaire


A health and wellness questionnaire is used to assess an individual’s level of fitness and the physical condition.  This type of questionnaire helps a person to find out the area of health where special consideration or improvement is needed. It is also necessary to fill the health and wellness questionnaire if an individual is planning to start weight training or strenuous physical activity for the first time.

The questionnaire also determines whether it is necessary to visit a physician before starting the training.

Health and Wellness Questionnaire Sample

All the information provided by you is strictly confidential

Name: ________________

Age: ___________________

Why according to you is healthy body important?

___________________________

What does health and wellness means to you?

___________________________

Have you been treated for any kind of heart disease in the past?

___________________________

Is there a chest pain whenever you are involved in a physical activity?

_____________________________

Are you under any medical supervision?

_______________________________

Is there any other activity that results in chest pain?

_______________________________

Have you ever fainted or felt nausea tic?

_____________________________________

Do you have high blood pressure problem?

_________________________________

Is it difficult for you to breathe whenever you exercise?

_________________________________________________

Are you aware of any medication that you are taking?

________________________________________

Are you currently pregnant?

____________________________________

Did you give birth to a child in last two months?

______________________________________

Did you have a surgery recently?

_______________________________

Do you have any physical disability or any condition that prevents you from exercising?

____________________________________

Do you have a high level of cholesterol?

___________________________________

___________________________________

Category: Health Questionnaire

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