Personal Health Values Survey When we know better we do better together!

Echo Laymon Pelster

Author, Certified LifeStyle & Weight Loss Coach,Master Storyteller & Keynote Speaker 308-325-3153 “When we know better we do better” Maya Angelou
Personal Health Values Survey

Please fill out this health survey
Name

First Name Last Name
Date

Month Day Year
Date
Email *
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred Contacts

Phone Call Email Phone Message Text Messages Other
Birth Date

Month Day Year
Age
Ex:23
Gender
Medical
Do you have any of the following?

High blood pressure Diabetes - Type 1 Diabetes - Type 2 Gout None of these Other
Are you taking any medications for

Diabetes Thyroid High blood pressure Lithium High cholesterol Coumadin (Warfarin) None Other
Are you pregnant?

Yes No N/A I’m a guy Other
Are you nursing?

Yes No Not applicable Other
Do you have any food allergies?

Yes No
What are you allergic to or intolerance of? *
BMI

Where are you now? Where would you like to be?
Height
Height in inches
Weight
Weight in lbs
What is your current BMI number?
What is the BMI value for the weight you want to maintain at?
Sleep
In general, at what time do you go to bed?
In general, when do you wake up?
On average, how many hours of sleep do you get?
Do you wake up feeling rested?

Yes No Wake up with a headache? Other
How is the quality of your sleep?
Hydration
In a day, how much water do you drink usually?
Do you use an 8 ounce glass? Imagine you did with this answer, 1-32 ounce would equal four glasses.
In a day, how much coffee do you drink usually?
One 16 ounce mug would equal 2 cups
In a week, how much alcohol do you consume usually?
1 to 2 glasses a week, more or less?
Movement
How many times per week do you exercise? Is there one exercise you preferred to do over another, is it more enjoyable or easier? Why do you think that is?
Do you do it because it’s easier because it’s fun?
What kind of exercise do you participate in? Do you like the exercise you participate in or do you do it because you think you should?
Walking? What do you enjoy most?
Are there things you would like to do that you are currently unable to? Physically? Financially? Emotionally? If you could over come One thing this year what would you do? Why would you do it?
Debt, weigh loss, fears?
How would you rate your daily energy level? *

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Stress
What do you do for work?
Office, labor, coach,
Do you enjoy what you do?
If you could do any job in the world what would you do? What do you imagine with fulfill your purpose more than anything else?
Are there any other stress in your life?
Just as financial stress affects our weight, so does relationships and emotional stress, what’s going on for you right now and how do you think it’s affecting you?
Rate your overall stress level

1

2

3

4

5

1 is Lowest, 5 is Highest
Eating Habits
When do you eat your first meal?
Is it breakfast when you wake up? Or do you start at another meal time?
When do you eat your last meal?
Do you have a normal dinner time in the evening or do you eat right before going to bed?
How many meals per day do you eat?
What diet and food programs have you tried in the past? Do you consider yourself a yo-yo dieter? Why do you think that is?
Could you get excited about never being on a diet again? Living a life of peace, joy, purpose and fulfillment around food? Why?
Have you had great success on a weight loss program in the past and then gained all the weight back?
Do you snack? If yes, what do you snack on?
How often do you eat out in a week?

Always Usually Sometimes Rarely Never Other
Have you had gastric bypass surgery in the past believing that it would solve your problem of being overweight? If so what happened?
Do you have hurts,habits,and hangups that you believe cause you to eat over eat or compulsively eat on a regular basis? Would you like to overcome your past? And have a brilliant future?
Where do you typically eat out? Do you have any Foods that once you start eating them you can’t stop? Describe them are they sugary? Fast food? Junk foods or processed foods?
Weight

I feel like I’ve tried everything and nothing has worked, I’ve lost hope and I know I must create a new lifestyle, the information out there is overload for me, I want to live a simpler happier life, with a healthy weight, and a lifestyle that makes sense, if this sounds like you keep going!
Current Weight
Goal Weight
Height
Have you tried to lose weight before?

Yes No
Do you feel you are food addicted? Do you have foods that once you start eating them you cannot stop? Do you feel that it is a certain type of food? Such as sugar or junk food? Why do you think that is?
Have you ever been embarrassed because you couldn’t fit into a chair? The seatbelt wouldn’t snap on the airplane and you had asked for an extender? You have to drive a bigger car because you can’t fit into the small economical car?
Do you plan your meals ahead? Do weekly grocery shopping? Shop with a grocery list? How often do you shop with a list and still buy or purchase things you didn’t plan on because you saw a sale or it just looked so good?
Are you constantly distracted with food and weight issues? Why do you think this is a distraction for you? What do you think you’re avoiding with this distraction?
When you eat your so-called comfort foods, do you feel relieved, a release of all anxiety, that the world is a better place at that moment, and then after it is all over you feel guilty for eating because the foods were not in alignment with your goal to be thin and lose weight? Would you like to overcome this forever?
Do you smoke? Do you desire to quit smoking?

1 Pack/day 2 Packs/day +3 Packs/day No Yes quitting is my goal.
Do you do any exercise?

1 - 3 a week 3 - 5 a week Everyday Never
Name one food that once you start eating it you can’t stop.
How many hours a night do you sleep? What keeps you up at night? Do you turn out the TV in the lights several minutes before you go to bed? Is it hard to go to sleep when you lay down at night?
I stay up late at night because… I can’t go to sleep because… I eat late at night and I can’t go to sleep…
Why do you want to lose weight now? For an event? To be healthier? To feel more confident? To feel better about yourself? Because deep down you know you’re worthy of feeling good and looking good, but you know you need help, because you don’t know what to do by yourself because of all the information overload out there?
Be healthier? Feel better? Look better?
Thank You! We will contact you shortly.
Echo Laymon Pelster

Author, Certified Lifestyle Coach, & Keynote Speaker

echopelster@echopelsterspeaks.com

www.echopelsterspeaks.com

Best-Selling Author featured in The Book on Transformation

Author of The Twisted Love of Food Addiction

308-325-3153
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Echo Laymon Pelster

Personal Health Values Survey

Medical

BMI

Sleep

Hydration

Movement

Stress

Eating Habits

Weight