9. How long have you been exercising regularly? _________ months
_________ years
10. What other exercise, sport, or recreational activities have you participated in? In the past 6 months? __________________________________________________ In the past 5 years? ____________________________________________________
11. Can you exercise during your work day? Yes
No
12. Would an exercise program interfere with your job? Yes
No
13. Would an exercise program benefit your job? Yes
No
14. What types of exercise interest you? Walking Cycling
Stationary biking Stair climbing
Jogging
Traditional aerobics Elliptical striding Swimming
Strength training Racquet sports Yoga/Pilates
Other activities
15. Rank your goals in undertaking exercise: What do you want exercise to do for you? _________________________________ _________________________________________________________________________________ _________________________________________________________________________________
Use the following scale to rate each goal separately: Not at all
important 1
2
Somewhat important
3 4 c. Reshape or tone my body
d. Improve performance for a specific sport e. Improve moods and ability to cope with stress f. Improve flexibility g. Increase strength
h. Increase energy level i. Feel better j. Enjoyment
k. Social interaction l. Other
(-) _________ lb 5
a. Improve cardiovascular fitness b. Lose weight/body fat
