Health History (Questionnarie)

Living Healthier Living Longer Program

Living Healthier Living Longer Health History Questionnaire_Form

Health History (Questionnarie)

OMB: 0990-0413

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Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Office on Women’s Health (OWH)

Living Healthier, Living Longer

Name ____________________________________________________________________________________
Date of Birth _____________________________________________________________________________
What is the best phone number at which to reach you? __________________________________________
ZIP code of residence ______________________________________________________________________
In case of emergency, please contact __________________________________________________________
At (insert phone number(s)): ______________________________________________________________
Background and General Health History
1. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or

government plans such as Medicare?
 No
 Yes
Have you had at least one menstrual period in the past 12 months? (Please do not include bleedings caused
by medical conditions, hormone therapy, or surgeries.)
 No
 Yes
 N/A
Have you smoked at least 100 cigarettes in your lifetime? (NOTE: 5 packs = 100 cigarettes)
 No (skip to question 5)
 Yes
 Don’t know/Not sure
Do you NOW smoke every day, some days or not at all?
 Every day
 Some days
 Not at all
 Don’t know/Not sure
Do you have any dietary restrictions or preferences?
 Gluten-free
 Vegetarian
 None
 Vegan
 Lactose free
 Other (please explain)___________________________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 4
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health &
Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Office on Women’s Health (OWH)

Living Healthier, Living Longer

6. Do you currently have or have a history of (check all that apply):






Diabetes
High blood pressure
Asthma or other lung disease
Pain in the legs that causes you to stop
walking
 Other conditions (mitral valve prolapse,
epilepsy, rheumatic fever, etc.) that may
hinder your ability to exercise







Chest discomfort with exertion
Dizziness, fainting, or blackouts
Shortness of breath at rest or with mild exertion
Labored breathing at rest or with mild exertion
Unusual fatigue or shortness of breath with usual
activities

 NONE OF THE ABOVE

7. Do you have a long-term physical or mental impairment that substantially limits one or more major life

activities?
 No (skip to question 9)
 Yes
8. In which activities are you limited (only respond if you answered “Yes” to question 7)?

 Caring for myself
 Performing manual
tasks
 Walking or standing

 Lifting or reaching
 Seeing
 Hearing, speaking or
communicating

 Learning, thinking or concentrating
 Working
 Other (please explain)_____________
_______________________________

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Office on Women’s Health (OWH)

Living Healthier, Living Longer

9. Using the circles on the left (click and drag), please add a circle to any areas of pain, injury, tension,

or restriction of movement.

10. If you circled any areas of pain, tension, or restriction of movement, please explain here:

__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Office on Women’s Health (OWH)

Living Healthier, Living Longer

11. Which of the following describes your previous attempts to lose weight (select all that apply)

 I have never tried to lose weight
 I have tried to lose weight by exercising
 I have tried to lose weight by dieting
 I have tried to lose weight with the aid of weight loss pills
 I have tried to lose weight with the aid of surgery
 Other (please explain)_______________________________________________________________)
12. Do you have any of the following negative feelings toward any exercise or exercise program the majority of
the time? Please select all that apply.
 Sweat makes me feel uncomfortable
 I have no negative feelings toward
 I am uncomfortable in a gym
exercise or exercise programs
 Exercise bores me
 Exercise is exhausting
 The information available about exercise is confusing
 I feel as though I do not benefit from exercise
 Exercise is too time-consuming
 Exercise programs are expensive
 I have been unsuccessful with previous exercise efforts
 Other (please explain)_____________________________
________________________________________________
______________________________________________

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Office on Women’s Health (OWH)

Living Healthier, Living Longer

Current Physical Activity
For questions 13 – 19, we are interested in your physical activity. Physical activities are activities where you
move and increase your heart rate above its resting rate, whether you do them for pleasure, work, or
transportation. Please refer to the following graphic for examples of physical activity intensity levels:
LIGHT activities
• Your heart beats
slightly faster than
normal
• You can talk and
sing
MODERATE
activities
• Your heart beats
faster than normal
• You can talk but not
sing
VIGOROUS
activities
• Your heart rate
increases a lot
• You can’t talk or
your talking is
broken up by large
breaths

Walking leisurely

Fast walking

Stretching

Aerobics class

Stair machine

Vacuuming; light yard
work

Strength training

Jogging or running

Swimming gently

Tennis, racquetball, or
badminton

13. During the last 7 days, on how many days did you do vigorous physical activities? Vigorous activities are

activities during which you heart rate increases a lot and you can’t talk (or talking is broken up by taking
large breaths).
_____days per week
 No vigorous physical activities (skip to question 15)
14. How much time did you usually spend doing vigorous physical activities on one of those days?

_____hours per day
 Don't know/not sure

_____minutes per day

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Office on Women’s Health (OWH)

Living Healthier, Living Longer

15. During the last 7 days, on how many days did you do moderate physical activities? Do not include

walking. Moderate activities are activities during which your heart beats faster than normal and you can
talk but not sing.
_____days per week
 No moderate physical activities (skip to question 17)
16. How much time did you usually spend doing moderate physical activities on one of those days?

_____hours per day
 Don't know/not sure

_____minutes per day

17. During the last 7 days, on how many days did you walk for at least 10 minutes at a time? Only include

those instances where you walked continuously for at least 10 minutes.
_____days per week
 No walking (skip to question 19)
18. How much time did you usually spend walking on one of those days?

_____hours per day
 Don't know/not sure

_____minutes per day

19. During the last 7 days, how much time did you spend sitting on a weekday? Remember to include time spent

sitting at home, at work, in your leisure time, or in a car.
_____hours per day
or
_____minutes per day
 Don't know/not sure

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Office on Women’s Health (OWH)

Living Healthier, Living Longer

Goals
20. Select all of the goals that are most important to you with your participation in this program:

 Improve overall health
 Improve endurance
 Improve
balance/coordination
 Improve exercise
knowledge

 Improve nutritional
knowledge
 Reduce stress
 Increase energy
 Increase flexibility






Increase strength
Have fun/socialize
Lose weight (_____ pounds)
Other (________________________
______________________________)

21. On a scale of 1-10, with 10 being 100 percent ready to take action, how ready are you to make lifestyle changes to
improve your health?

 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

22. What factors might keep you from reaching your health and fitness goals?

Form Approved
OMB No. 0990Exp. Date XX/XX/20XX

Office on Women’s Health (OWH)

Living Healthier, Living Longer

Please take a moment to carefully read the following information and sign where indicated.
I acknowledge that I have voluntarily chosen to participate in a nutrition and physical activity program, and that
the nutrition and exercise information I receive is provided for the purpose of instruction and guidance. I further
understand that personal trainers, nutritional consultants, and other instructors involved in this program are not
qualified to perform, diagnose, or treat any physical or mental illness, and that nothing said in the course of this
program should be considered as such. I fully understand that I may injure myself as a result of my participation
in this program and I hereby release The Office on Women’s Health, The Lewin Group, and SAGE and (and all
staff and affiliates) from any liability now or in the future for conditions that I may obtain. These conditions
may include, but are not limited to, heart attacks, muscle strains, muscle pulls, muscle tears, broken bones, shin
splints, heat prostration, injuries to knees, injuries to back, injuries to foot, allergic reaction, or any other illness
or soreness that I may incur, including death. Additionally, I understand that I am responsible for monitoring
my own condition throughout the exercise program.
Note: To reduce the risk of any injury and /or illness, before beginning this or any nutrition and physical
activity program, please seek medical advice for guidance regarding appropriate dietary changes, exercise
levels and precautions. It is particularly important to seek such advice if you suffer from an ongoing medical
condition which may be affected by change in diet or exercise. The nutrition and exercise instruction and advice
presented is for information purposes only and is in no way intended as a substitute for medical consultation.
The Office on Women’s Health, The Lewin Group, and SAGE accept no liability from and in connection with
this program.
By signing this document, I assume all risk for my health and well-being and hold harmless of any
responsibility, The Office on Women’s Health, The Lewin Group, and SAGE, and affirm that I have
read and fully understand the above statements.
Signature___________________________________________

Date____________________

End of Questionnaire

File Type	application/pdf
File Title	Microsoft Word - Living Healthier Living Longer Health History Questionnaire_Form
Author	allison.rizer
File Modified	2013-08-26
File Created	2013-08-26