Crossroads Life Coaching International

Crossroads Life Coaching International

(Healthy Lifestyle Habits Assessment from Clarence Brown)
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Group ID
Rate your level of satisfaction with how you are doing in each of the following health pratices:

1=lowest satisfaction level, and 10 =highest satisfaction level
Regular healthy meals: fruit, vegetables, legumes and whole grains, no snacking *

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Meat, Poultry, Dairy, Consumption*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Convenience and/ deep fried foods consumption*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Adequate water consumption*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Regular Healthy Breakfast*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Regular exercise: cardio, strength & flexibility, walking*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Stress management*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Adequate sleep*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Caffeine, Alcohol and tobacco consumption*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Work/Life balance*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Spirituality*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Fun and leisure time/activities*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Use of toxin-free products*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Positive mind frame*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Organization/order*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Financial management*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
sugary drinks, deserts and process food consumption*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Describe in more detail 1 to 5 areas you’d most like to focus on.*
How long has it been since your last physical?
What disease condition(s) are you most concerned about preventing, managing or possibly reversing
When is the best time to contact you?
Thanks you for taking this assessment to help with developing your life style plan. I look forward to reviewing your responses during our discovery session to complimentary discovery session
Should be Empty: