B.A.S. Wellness, LLC
Suite 104
601 Keisler Drive
Cary, NC, 27511
919-624-6707
bernie@baswellness.com

Activity and Goals Questionnaire

Name

Email (REQUIRED)

Phone

Check the appropriate number (0-7) below which best describes your general activity level for the previous month: (Check one box only, please)

I do not participate regularly in recreation, sport or heavy physical activity;
	(Level 0) I avoid walking or exertion, e.g., always use elevator, drive whenever possible instead of walking.
	(Level 1) I walk for pleasure, routinely use stairs, occasionally exercise sufficiently to cause heavy breathing or perspiration.

I participate regularly in recreation or work requiring modest physical activity, such as golf, horseback riding, calisthenics, gymnastics, table tennis, bowling, weight lifting, yard work;
	(Level 2) I perform 10-60 minutes per week of these activities.
	(Level 3) I perform over 1 hour per week of these activities.

I participate regularly in heavy physical exercise such as running or jogging, swimming, cycling, rowing, skipping rope, running in place, or engaging in vigorous aerobic activity type of exercise such as tennis, basketball or handball;
	(Level 4) I run less than one mile per week or spend less than 30 minutes per week in comparable physical activity.
	(Level 5) I run 1 to 5 miles per week or spend 30-60 minutes per week in comparable physical activity.
	(Level 6) I run 5 to 10 miles per week or spend 1 to 3 hours per week in comparable physical activity.
	(Level 7) I run over 10 miles per week or spend over 3 hours per week in comparable physical activity.

Please indicate the exercise activities you do most frequently now:

Type	Times/week	Years	Duration
	/wk		min
	/wk		min
	/wk		min

Define Your Goals:
-These goals must be SMART goals. SMART goals are:
Specific: Make your goals clear and precise.
Measurable: Measurable goals allow you to track your progress.
Action-orientated: Make goals that include action. To change you must DO something.
Realistic: Choose goals that are within your reach. Work on small lifestyle changes that are doable for you.
Timed: Give yourself a timetable to complete your specific, measurable, and realistic action.

-Remember, you should be encouraged by your goals, not overwhelmed. Use positive phrases to state your goals (i.e. be more active vs. be less sedentary).

A. List your long-term goals (What I want to accomplish in 6 months to a year):

B. List your short-term goals (What I want to accomplish in 3-6 months):

Thank You!
Based on the information provided (health history, activity level, and goals), we will be able to develop the most appropriate and safe exercise prescription for you.