ASSESSMENT FORM

PERSONAL HEALTH AND FITNESS PROFILE INFORMATION

Adapted from the book of “Fit to be Well Essential Concepts” By: Alton and Steven
Thygerson

Last Name

First Name

Middle Name

Age Sex Civil Status

Birthdate

Birthplace

Address

Contact no.

E-mail Address

Blood Type Body Fat

Weight (kg) Height (m)

Ideal Weight BMI

Basal
Metabolic Rate

Suggested
Calorie Intake

Target Heart Average

Rate Resting Rate
 Health Style: A Self-Test
This self-test, is a modified version of the one
developed by the U.S. Public Health Service, assesses
several health-related behaviours. Although these
behaviours apply to most individuals, people with chronic
health concerns should follow the advice of their physicians.

DIRECTIONS: Answer each of the following questions by encircling the number of the
response that applies best to you. Add the number of points under
each health-related behaviour category to obtain a score for that
category. Use the scoring guide at the end of the test to determine the
level of risk you are incurring by your health-related behaviour.

TOBACCO, ALCOHOL, AND OTHER DRUGS

ALMOST ALMOST
SOMETIMES
ALWAYS NEVER
1. I avoid using tobacco products. 3 1 0

2. I smoke only low-tar cigarettes. 3 1 0

SMOKING SCORE:

3. I avoid drinking alcoholic beverages,

or I drink no more than one or two 3 1 0
drinks per day.

4. I avoid using alcohol or other drugs

(especially illegal drugs) as a way of
3 1 0
handling stressful situations or
problems in my life.

5. I avoid driving while under the

3 1 0
influence of alcohol and other drugs.

6. I am careful not to drink alcohol when

taking certain pain medications or 3 1 0
when pregnant.

7. I read and follow the label directions

when using prescribed and over-the- 3 1 0
counter drugs.

ALCOHOL AND OTHER DRUGS

SCORE:
 EATING HABITS

ALMOST ALMOST
SOMETIMES
ALWAYS NEVER
8. I eat a variety of foods each day,
including fruits and vegetables,
whole-grain products, lean 3 1 0
meats, low-fat dairy products,
seeds, nuts, and dry beans.

9. I limit the amount of fat that I

eat especially animal fats such
3 1 0
as cream, butter, cheese, and
fatty meats.

10. I limit the amount of salt that I

eat by avoiding salty foods and 3 1 0
not using salt at the table.

11. I avoid eating too much sugar

by eating a few sweet snacks 3 1 0
and limiting sugary soft drinks.

EATING HABITS SCORE:

EXERCISE/FITNESS

ALMOST ALMOST
SOMETIMES
ALWAYS NEVER
12. I maintain a body weight that is
3 1 0
reasonable for my height.

13. I do vigorous exercise (for

example, running, swimming, or
brisk walking) for at least 30 3 1 0
minutes at least three times per
week.

14. I do different exercises to

enhance my muscle tone and
flexibility (for example, yoga or 3 1 0
calisthenics) for 15 to 30 minutes
at least three times per week.

15. I use part of my leisure time

participating in individual, family,
or team activities that increase my
3 1 0
level of physical fitness (for
example, gardening, bowling, or
golf).

EXERCISE/FITNESS SCORE:
 STRESS MANAGEMENT

ALMOST ALMOST
SOMETIMES
ALWAYS NEVER
16. I take time every day to relax. 3 1 0

17. I find it easy to express my

3 1 0
feelings.

18. I recognize and prepare for

events or situations that are 3 1 0
likely to be stressful.

19. I have close friends, relatives, or

others I can talk to about
3 1 0
personal matters and contact for
help when needed.

20. I participate in hobbies that I

enjoy or group activities such as
3 1 0
religious or community
organizations.

STRESS MANAGEMENT SCORE:

SAFETY

ALMOST ALMOST
SOMETIMES
ALWAYS NEVER
21. I wear a seat belt while riding in
3 1 0
a motor vehicle.

22. I obey traffic rules and speed

3 1 0
limits while driving.

23. I have a working smoke detector

3 1 0
in my home.

24. I am careful when using

potentially harmful products or
substances, such as household 3 1 0
cleaners, poisons, and electrical
devices.

25. I avoid smoking in bed. 3 1 0

SAFETY SCORE:

Healthstyle: A Self-Test 309-310

© 2019 Jones & Bartlett Learning, LLC
 WHAT DOES YOUR
SCORE MEAN?

SCORES OF 9 OR 10 FOR EACH SECTION

Excellent! Your responses show that you are aware of the importance of this area
to your health, and that you are practicing good health-related habits. As long as
you continue to do so, this area of health should not pose a risk.

SCORES OF 6 TO 8 FOR EACH SECTION

Your health practices in this area are good, but there is room for improvement. Look
at the items that you answered with “Sometimes” or “Almost Never”. What lifestyle
changes can you make to improve your score and reduce your risk?

SCORES OF 3 TO 5 FOR EACH SECTION

Your health-related behaviours are risky. What lifestyle changes can you make to
improve your score in this area of health and reduce your risk?

SCORES OF 0 TO 2 FOR EACH SECTION

You may be taking serious and unnecessary risks with your health and possibly, the
health of others. What lifestyle changes can you make to improve your score and
reduce your risk?

© Healthstyle: A Self-Test, Hyattsville, MD: U.S. Public Health Service,198

PAR-Q & You: A Questionnaire for People Aged 15 to 69

Regular physical activity is fun and healthy, and increasingly more people are
starting to become more active every day. Being more active is very safe for most
people. However, some people should check with their doctor before they start
becoming more physically active.

If you are planning to become much more physically active than you are now,
start by answering the seven questions in the box below. If you are between the ages
of 15 and 69, the PAR-Q will tell you whether you should check with your doctor
before you start. If you are older than 69 years of age, and you are not used to being
very active, check with your doctor.

Common sense is your best guide when you answer these questions. Please
read the questions carefully and answer each one honestly. Check Yes or No.
YES NO Specific Techniques
Has your doctor ever said that you have a heart condition and that
1. you should only do physical activity recommended by a doctor?

2. Do you feel pain in your chest when you do physical activity?

In the past months, have you had chest pain when you were not
3.
doing physical activity?

Do you lose your balance because of dizziness, or do you ever lose

4.
consciousness?

Do you have a bone or joint problem (for example, back, knee, or

5. hip) that could be made worse by a change in your physical
activity?

Is your doctor currently prescribing drugs (for example, water

6.
pills) for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical
7.
activity?

If you answered YES to one or more questions

Talk with your doctor by phone or in-person BEFORE you start becoming much more
physically active or BEFORE you have a fitness appraisal. Tell your doctor about the
PAR-Q and which questions you answered YES.

●You may be able to do any activity you want—as long as you start slowly and
build up gradually. Or, you may need to restrict your activities to those that
are safe for you. Talk with your doctor about the kinds of activities you wish
to participate in and follow his or her advice.
●Find out which community programs are safe and helpful for you.

If you answered NO to one or more questions

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that
you can:

●Start becoming much more physically active—begin slowly and build up

gradually. This is the safest and easiest way to go.
●Take part in a fitness appraisal—this is an excellent way to determine your
basic fitness so that you can plan the best way for you to live actively. It is
also highly recommended that you have your blood pressure evaluated. If
your reading is over 144/94, talk with your doctor before you start becoming
much more physically active.
Delay Becoming Much More Active:

 If you are not feeling well because of a temporary illness

such as a cold or a fever—wait until you feel better; or

 If you are or may be pregnant—talk to your doctor before

you start becoming more active.

PLEASE NOTE:
 If your health changes so that you then answer YES to any of
the preceding questions, tell your fitness or health
professional.
 Ask whether you should change your physical activity plan.
Informed Use of the PAR-Q: The Canadian Society for Exercise
Physiology, Health Canada, and their agents assume no
liability for persons who undertake physical activity, and if in
doubt after completing this questionnaire, consult your doctor
prior to physical activity.
 No changes are permitted. You are encouraged to
photocopy the PAR-Q but only if you use the entire
form.

NOTE:

If the PAR-Q is being given to a person before he or she participates in a physical

activity program or a fitness appraisal, this section may be used for legal or
administrative purposes.

“I have read, understood, and completed this questionnaire. Any questions I had
been answered to my full satisfaction.”

NAME
Note:
This physical activity clearance is valid
SIGNATURE for a maximum of 12 months from the
date it is completed and becomes invalid
if your condition changes so that you
would answer YES to any of the seven
DATE
questions.

WITNESS OR GUARDIAN
(for participants under the age of majority)
 What keeps you from being active?

BARRIERS TO BEING ACTIVE

DIRECTIONS: Listed below are reasons that people give to describe why they do not
get as much physical activity as they think they should. Please read
each statement and indicate how likely you are to say it.

VERY SOMEWHAT SOMEWHAT VERY

How likely are you to say?
LIKELY LIKELY UNLIKELY UNLIKELY

My day is so busy now; I just don’t

think I can make the time to include
physical activity in my regular 3 2 1 0
schedule.
None of my family members or friends
likes to do anything active, so I don’t 3 2 1 0
have a chance to exercise.

I’m just too tired after work to get

any exercise. 3 2 1 0

I’ve been thinking about getting more

exercise, but I just can’t seem to get 3 2 1 0
started.
I’m getting older so exercise can be
3 2 1 0
risky.
I don’t get enough exercise because I
have never learned the skills for any 3 2 1 0
sport.
I don’t have access to jogging trails,
swimming pools, bike paths and so 3 2 1 0
forth.
Physical activity takes too much time
away from other commitments—work, 3 2 1 0
family and so on.
I’m embarrassed about how I will look
3 2 1 0
when I exercise with others.
I don’t get enough sleep as it is. I just
couldn’t get up early or stay up late to 3 2 1 0
get some exercise.
It’s easier for me to find excuses not
to exercise than to go out and do
3 2 1 0
something.
 I know of too many people who have
hurt themselves by overdoing it with 3 2 1 0
exercise.
I really can’t see learning a new sport
3 2 1 0
at my age.
It’s just too expensive. You have to
take a class or join a club or buy the 3 2 1 0
right equipment.
My free times during the day are too
3 2 1 0
short to include exercise.
My usual social activities with family
or friends do not include physical 3 2 1 0
activity.
I’m too tired during the week and I
need the weekend to catch up on my 3 2 1 0
rest.
I want to get more exercise, but I just
can’t seem to make myself stick to 3 2 1 0
anything.
I’m afraid I might injure myself or
3 2 1 0
have a heart attack.
I’m not good enough at any physical
3 2 1 0
activity to make it fun.
If we had exercise facilities and
showers at work, then I would be 3 2 1 0
more likely to exercise.

Follow these instructions to score yourself:

 Enter the encircled number in the spaces provided below, putting together the number for statement 1 on
line 1, statement 2 on line 2, and so on.
 Add the three scores on each line. Your barriers to physical activity fall into one or more of seven
categories: lack of time, social influences, lack of energy, lack of willpower, fear of injury, lack of skill, and
lack of resources. A score of 5 or above in any category shows that this is an important barrier for you to
overcome.

+ + =
1 8 15 Lack of time
+ + =
2 9 16 Social influence
+ + =
3 10 17 Lack of energy
+ + =
4 11 18 Lack of motivation
+ + =
5 12 19 Fear of injury
+ + =
6 13 20 Lack of skill
+ + =
7 14 21 Lack of resource
 For high-scoring barriers (5 or more scores), use the following strategies. Place a
What to do? checkmark next to the strategies attempted.

Content in the ―Personal Barriers‖ section was taken from Promoting Physical Activity: A Guide for Community Action (USDHHS, 1999).