Initial Lifestyle Assessment Questionnaire


I believe that every worthwhile journey has a starting point in which we begin. When you understand where you are today, your goals become clearer and easier to reach. You become more focused on your goal and that provides you with the drive and the motivation to reach it.

Using this same idea you might find that by simply completing this free assessment, your lifestyle goals become clearer and more defined. What does it take for you to reach that goal?

You will receive a multi-page, detailed report from me by email so make sure to have your email address correct. The report will be in a text file that any word processing program can read.

You don't have to fill out all the information but the more information you do fill in, the more detailed my report will be to you. For any information that you don't know, I will use the normal range for a person that fits your body style and height/weight. I have several formulas that my systems use to compute the different nutrition and lifestyle recommendations.

Remember, this is just my initial report and clients receive regular detailed reports that track every aspect of their journey along with tools that condition the mind as well as the body and spirit. It is the mind, body, and spirit connection that takes weight management from a cold, hard restrictions, to a lifestyle change that we truly enjoy and benefit from.

I process these assessments every work day so I can get these back to you in 24 to 48 hours. Sometimes because of my schedule it might take longer for me to process your report.

Please complete the following form:


Required information.Optional information.

Contact Information

First Name: MI: Last:
Address Line 1:
Address Line 2:
City: State: Postal Code:
Country: Email: Phone:

 
Unit of Measure
Select the unit of measure you wish to use for height and weight entries:
English (inches, lbs)   Metric (cm, Kg)

 

Personal Information
Sex: Female Male
Pregnant/Nursing: n/a Pregnant Nursing
Height: inches/cm Age:

 

Body Frame
If you don't already know your body frame type, try this: place your thumb and middle finger around your wrist. If they overlap, enter "small." If they just touch, enter "medium." If they don't touch, enter "large."
Body Frame: Small Medium Large

 

Activity Level
Check the appropriate activity level that most closely approximates your lifestyle. Examples:
Sedentary = working behind a PC. Moderately Active = waiting tables. Active = construction work.

Activity level: Sedentary Moderately Active Very Active

 

Body Weight
Present Weight: lbs/Kg     Desired Weight: lbs/Kg
Desired loss/gain per week: lbs/Kg
Body Weight Charts for WomenBody Weight Charts for Men
 
 
Resting Heart Rate

Resting Heart Rate:

Please enter your heart rate, measured first thing in the morning before you get out of bed.
 
Percentage Body Fat Composition Values
Present % Body Fat Content:     Desired % Body Fat Content:
Please enter both values if you want calculations to be based on your body fat content.
Body fat calculations will override any value you may have entered for Desired Weight.
Body Fat Chart for Women and Men

 

Daily Exercise Calorie Expenditure Goals

Exercise Calorie Goal - Monday:  

    calories

Exercise Calorie Goal - Tuesday:  

    calories

Exercise Calorie Goal - Wednesday:  

    calories

Exercise Calorie Goal - Thursday:  

    calories

Exercise Calorie Goal - Friday:  

    calories    

Exercise Calorie Goal - Saturday:  

    calories

Exercise Calorie Goal - Sunday:  

    calories

Exercise Calorie Expenditures Sorted by Activity     Exercise Calorie Expenditures Sorted by Intensity

 

PCF Ratio Goal
If you aren't sure what your ratio should be, leave them blank... our Nutrition Coaches will recommend
one for you. Enter your goal for these three variables as a percentage of your total daily calorie intake:
% Protein Calories: % Carbohydrate Calories: % Fat Calories:
(These three percentages must equal 100%. If they don't, we'll enter values for you.)

 

Personal Goal
This selection is optional. Please select the option that most closely describes your goal:
Lose Weight Maintain Weight Gain Weight Increase Athletic Performance

 

Peak Body Weight

What is the most you ever weighed?:  

lbs/Kg

When did you weigh this amount?:  

 

Medical Conditions
Please select as many as apply:

  Anemia
  Asthma
  Colitis
  Diabetes
  Gastric Reflux
  Hypertension

Hypoglycemia
Irritable Bowel Syndrome
Heart Disease
Hiatal Hernia
Liver Disease
Other (specify):

 

Comments and Additional Information
Please enter additional information you feel is important to consider in your personal assessment.