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
1. 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
2. Meat, Poultry, Dairy, Consumption*

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
6. Regular exercise: cardio, strength, flexibility, walking and relaxation *

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
7. Stress and anxiety management*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
8. Adequate sleep and fresh air*

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
9. Caffeine, Alcohol, tobacco consumption and frequent prolong sitting over 2 hours per day.*

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
11. Spirituality and Faith community involvement*

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

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

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
17. 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
🔷 1. MOVEMENT & METABOLISM SCORE
🔸 2. Nutrition & Detoxification:
🔵 3. Mind & Restoration:
🟣 Overall_Lifestyle_Score
🔷 1. MOVEMENT & METABOLISM: Health Zone
🔸 2. Nutrition & Detoxification: Health Zone:
🔵 3. Mind & Restoration: Health Zone:
🔷 1. MOVEMENT & METABOLISM SCORE: Health Zone Description:
🔸 2. Nutrition & Detoxification: Health Zone Description:
🔵 3. Mind & Restoration: Health Zone Description:
Beloved, I wish above all things that thou mayest prosper and be in health, even as thy soul prosper.” — 3 John 1:2 (KJV)

Crossroads Life Coaching — A Blend of Both Faith + Holistic Health
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: