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  2. 2010
  3. October
  4. B
  5. Breakthrough Sports and Fitness Wellness Manual
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Welcome to the Breakthrough Wellness Program.

The questions in the following sections will help us to understand your needs. Please answer honestly and in as much detail as you are able.

The answers to your questions will be treated with the utmost confidentially.

Sincerely.
Harold Hugel
Ryan Mitra
 
 
Contact Information
* First Name : 
* Last Name : 
* Address 1 : 
   Address 2 : 
* City : 
* Province : 
* Postal Code : 
* Phone : 
* Email Address : 
 
Physical Activity Readiness Questionnaire

This questionnaire is designed for people between the ages of 15 to 69.

If you are considering becoming more physically active, then you should start by honestly answering the following questions. If you answer “Yes” to any of these questions, discuss this questionnaire with your doctor and get a signed consent form from you doctor indicating that you are able to increase your physical activity.

If you are younger or older than the 15 to 69 age range, we will need a signed consent form from your doctor, indicating that you are able to increase your physical activity.

Please answer Yes or No for the following questions:
Yes No
* 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
* 2. Do you feel pain in your chest when you do physical activity?
* 3. In the past month, have you had chest pain when you were not doing physical activity?
* 4. Do you lose your balance because of dizziness, or do you ever lose consciousness?
* 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
* 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
* 7. Do you know of any other reason why you should not do physical activity?
 
 
Health and Lifestyle Questionnaire.
If you answer "Yes" to any question, please describe in the next section.
Yes No
1. Are you experiencing any stresses, mood problems, relationship difficulties, or substance-related problems for which you would like resource or referral information on a confidential basis?
2. Do you occasionally use or are you currently taking any prescription or over-the-counter medications?
3. Have you had any surgical operations in the last 10 years?
4. Has anyone in your immediate family developed heart disease before the age of 60?
5. Do any diseases run in your family?
6. Do you currently have a cold/cough, or have you had any in the last two weeks?
7. Do you know of any other reason why you should not do physical activity?
8. Are you a current or former cigarette smoker? If Yes, please indicate in the next section i) Packs per day; ii) Number of years smoked; and iii) When you quit.
9. Do you drink more than 9 drinks per week? If Yes, please indicate in the next section i) Number of beers; ii) Ounces of Liquor; and iii) Ounces of Wine per week.
10. Has it been more than 2 years since your last health maintenance screening test? If "Yes", please book an appointment with your doctor.
11. Do you have trouble getting to sleep or staying asleep?
 
 
 
Question 2. List Prescription Drugs/Supplements:
   
Question 3. Explain any surgeries you have had:
   
Question 5. Describe diseases in your family:
   
Question 7. Physical Limitations:
   
Question 8: Smoker: Packs per day? How many years have you smoked? When did you quit?
   
Question 9. Alcohol per week: Number of beers? Ounces of alcohol? Ounces of wine?
   
Other items we should know?
   
 
 
 
Given the following goals, please rank from most important (1) to least important (8)
Improved Health:
Improved Endurance:
Increased Strength:
Increased Muscle Mass:
Fat Loss:
Increased Power:
Weight Gain:
Sport Specific (list sport):
 
 
 
Do you have a specific timeline to reach a specific goal? If so please specify:
   
 
 
Fill in the type of exercise using the following: Resistance Training (RT); Interval Cardo (INT); Low-intensity cardo (LIC); Sport Specific (SSW). Also indicate the workout duration in minutes.
Activity Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
 
Readiness for Change Questionnaire: Read the following and answer as honestly as possible.

If there is no description assume YES=A, NO=B, NOT SURE=C. For example if you answer YES to the first question on Appearance, tick the A box.
A B C
Appearance: Are you distressed or embarrassed by your physical appearance?
Medical Condition: Are you taking medications for cardio-vascular related issues and/or blood sugar issues? A=two or more, B=one, C=None
Physical Fitness: Are you willing to devote at least five hours of structured physical activity per week?
Health Concerns: How do explain that you are not in the shape that you would like? A=Family History/Aging, B=Not Active Enough, C=Not Sure
Social Network: Do the people in your lives follow good nutrition (no donuts at work, eating right when going out), good exercise (three times per week), less than three alcoholic drinks per week and take nutritional supplements?
Employment: If your work environment is an impediment to better health, would you be willing to discuss options with your employer or switch jobs?
Advice of Others: If a friend or loved one gives you reasons why you can’t succeed (failed before, family history, hormonal issues etc), how will you respond? A="I can do it", B="I'll take it one day at time", C="Maybe you're right"
 
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