Health Survey

Complete all health and fitness status questions. Ask for assistance from
your parents or guardians if needed.
Personal Information
Height 59
Weight 154.8
Health Status
1. 1.
Yes_____ No___X___ Do you have any medical situation that would
limit your participation in any physical activity?
*If yes, please write a detailed explanation of the medical issue and the
specific activities you cannot participate in.

2. Rate your present medical condition:

_____
Excellent
__X___
Good
_____ Fair
_____ Poor
*If you selected Fair or Poor and you do not have a condition that is
explained in item #1, explain why you have rated yourself in this way.
3. Describe two or more physical activities you participate in outside of a
school setting. They could be within your city, community, neighborhood
or family. Include how often you participate, such as a daily or weekly
basis.
I go to the gym with my mom every morning and walk/run on the
treadmill or do a class like a spin class.
4. Explain how your friends positively and negatively influence your
decisions to be physically active and to make healthy choices.
They are very supportive
5. What areas of your health and body would you like to improve?
_____ Flexibility
__X___ Cardiovascular endurance
__X___ Upper body strength
_____ Lower body strength
__X___ Body composition
__X___ Increase weight
_____ Decrease weight

_____ Decrease percentage of body fat

__X___ Increase physical activity level
6. Go to the course Announcement page. List three things from the
Announcement page content that you will use to help you succeed in
your Personal Fitness course OR three things that you would like to see on
your course Announcement page which might be beneficial to you.
A.I did not see any announcements on the course announcements
page as of yet.
B.
C.