Habit Tracker

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Habit Tracker

Habit Tracker and Physical Activity Readiness Questionnaire

Name:

Email Address (optional)

Phone (optional)

Age

Height in cms

Weight in kgs

1 being poor and 5 being great, please rate your current physical condition

1

2

3

4

5

Hours of Physical Activity per week

0

1 - 2

3 - 4

5+

Fast Food Consumption

1 -3 days

3 - 5 days

Weekly

Monthly

Never

If you do please give details

Alcohol Consumption

Every day

Weekends only

Occasionally

Never

Smoke

Yes

No

If yes then how many per day

Hours sitting per day

1 - 4

4 - 8

8 - 12

12+

Hours of Sleep per night

3 - 5

6 - 8

9+

Blood Pressure

Low

Normal

High

Unsure

Heart Problem

Yes

No

If yes, please describe

Diabetes

Yes

No

Asthma

Yes

No

Arthritis

Yes

No

Joint Aches and Pains

Neck

Shoulder

Spine and lower back

Hip and knee

Ankle and foot

Any other relavent information

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