Baseline Health Assessment
Current LifeStyle Information
Nutrition
How would you describe your personal eating habits?
They are great
They're good
They're ok but could be better
They need work
How often do you eat well balanced meals
Always- Every meal is well balanced
Often- I try but sometimes I fall short
Occasionally- I have healthy meals but not regularly
Rarely- My diet is often unbalanced
How much fruits and vegetables do you incorporate into each meal?
5+ servings( great intake)
3-4 servings(moderate intake)
1-2 servings(rare intake)
None or very rarely
Do you currently or have you ever experienced any of the following food related issues?
Acid reflux or heartburn
Blood sugar crash(fatigue, dizziness after eating)
Sugar cravings or dependency
Difficulty maintaining a healthy weight
Describe your current water intake.
8+ cups a day(fully hydrated)
5-7 cups a day(moderately hydrated)
3-4 cups a day(low hydration)
Less than 3 cups a day(dehydrated)
What would be a personal goal you would like to work on with your nutrition? (Not S.M.A.R.T format)
Physical Activity
How would you describe your current physical activity habits?
Excellent ( I make an effort to make it to the gym every day)
Good ( I go at least 3 times a week)
Okay ( I go once or twice a week)
I need help ( I don't go at all
What kinds of activities do you enjoy that you would like to incorporate into a routine?
Aerobics
Running
Circuit Training and Weight Lifting
Another type of exercise that is not listed here
How often do you experience any barriers with your physical activity?
Never
Occasionally
Freequently
Always
Have you ever or are currently experiencing anything while engaging in physical activity?
No I feel great
Minor aches, but nothing serious
I have pain that impacts my activities
Pain constantly affects my daily life
How many minutes a week are you currently active?
Daily (30 minutes a day)
A few times per week
Occasionally (Once or twice a week)
Rarely or never
What is one goal that you would like to improve with your physical activity habits?(not in S.M.A.R.T format)
Body Weight
Describe your past experiences with your weight loss journey
Great (I've had a lot of success)
Good (I've had some accomplishments)
Okay (I've had some successes but I need some guidance)
Hard (I could use some help)
How many success have you had in your weight loss journey?
4+
3-4
2-3
1-2
How many challenges have you had in your weight loss journey?
4+
3-4
2-3
1-2
How do you feel in your body currently?
Excellent (No health issues)
Good (Some minor health issues but I feel fine)
Fair( I have a few health issues that have an impact on my routine)
Poor ( I struggle with many health issues that affect my routine)
Have you experienced any weight loss in the past 6 months?
No weight change
Gained weight intentionally
Lost weight intentionally
I have actively worked on my weight management
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What is a personal goal you would like to work towards with your weight management?(not in S.M.A.R.T format)
Tobacco
Is tobacco use a current habit in your lifestyle?
Yes (Daily)
A few times per week
Occasionally
Rarely or never
How often do you smoke every day?
I smoke a pack a day
2-3 throughout the week
1-2
none at all
Describe your past attempts in quitting smoking.
Great (I've had a lot of success)
Good (I've had some accomplishments)
Okay(I've had some success but I need some help)
Hard ( I need some help)
How many successes have you had in attempting to quit?
4+
3-4
2-3
1-2
How many challenges have you had in attempting to quit?
4+
3-4
2-3
1-2
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Next
What is a personal goal you would like to accomplish in the next 6 months? (not in S.M.A.R.T format)
Alcohol
Is alcohol a current habit in your every day life?
Yes (Daily)
I have a few drinks a week
Occasionally
Rarely
How many drinks do you consume daily?
4+
2-3
1-2
None at all
Describe your past attempts in eliminating alcohol from your lifestyle.
Great (I've had a lot of success
Good (I've had some accomplishments)
Okay (I've had some successes but could use some guidance)
Hard( I need some help)
How many successes have you had in reducing alcohol in your life?
4+
2-3
1-2
None at all
How many challenges have you had in reducing alcohol in your life?
u4+
2-3
1-2
None at all
What is a personal goal you would like to accomplish with your alcohol use? (not in S.M.A.R.T format)
Sleep
How would you describe your sleeping habits currently?
Great(I've had a lot of success)
Good( I've had some accomplishments)
Okay (I've had some successes but I need some guidance)
Not great( I need some help)
On average how many hours of sleep do you get each night?
8+
6-8
4-6
Less than 4(I need some help)
How would you describe your sleeping habits throughout the week compared to the weekend?
It's great( I get the right amount of sleep each night of the week)
It's good( I do ok throughout the week but I do better on the weekends)
It's ok ( I get the right amount of sleep to function throughout the day and week)
Not great (I need guidance on how I can improve my overall sleeping habits)
How many successes have you had with your sleeping habits in the past 6 months?
4+
2-3
1-2
None at all
How many challenges have you had with your sleeping habits in the past 6 months?
4+
2-3
1-2
None at all
What is a personal goal you would like to work on towards your sleep?( not in S.M.A.R.T format)
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Stress
How does your current stress level make you feel?
Panicky
Overwhelmed
Nervous
Okay (Stress doesn't affect me)
What is one thing right now that contributes to your current stress level?
Work
Financial Responsibilities
Family Responsibilities
Something else
What are some of your current stress management techniques?
Exercise
Meditation
Therapy
Something else
How does your stress level affect your overall health?
Headaches, muscle tension or body aches
Mood swings
Digestive Issues
I usually don't experience anything
How often do you experience stress?
Rarely (I manage stress well)
Occasionally (I experience stress but I can handle it)
Frequently (Stress overwhelms me)
Constantly (I feel stressed all the time)
What is a personal goal you would like to work on with your stress management(not in S.M.A.R.T format)
Should be Empty: