LifeStyle Evaluation
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Gender
*
Male
Female
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
-
Area Code
Phone Number
Height
*
Bone Size
*
Small
Medium
Large
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Life Situation
Marital Status
*
Married
Common law
In a relationship
Single
Divorced
Widow
Do you have children?
*
Yes
No
How many?
How old are they?
How many people live in your household?
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Stress
How would you rate your stress levels from 1-5 (1 = very low, 5 = very high)?
*
Which of the following best describes your current stress(es)?
*
Family
Financial
Work
Personal
Illness
Travel
Sleep Disruption
Other
Are these stresses keeping you from following your nutrition and lifestyle program?
*
YES
NO
How are you currently managing your stress (e.g.,meditation, yoga, deep breathing)?
*
Have you heard of Mindfulness Meditation?
*
YES
NO
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Exercise
How would you rate your exercise enjoyment from 1-5 (1 = very low, 5 = very high):
*
How many times per week do you exercise?
*
For how long?
*
Are you working with a trainer?
*
YES
NO
Who is your trainer?
What are you doing (be specific)?
*
What are your athletic goals?
*
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Sleep
How would you rate your energy levels from 1-5? (1 = very low; 5 = very high)
*
How many hours of sleep are you getting per night?
*
Do you take naps during the day?
*
YES
NO
What is your quality of sleep?
*
Excellent
Good
Okay
Poor
How do you feel upon walking?
*
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Weight Management
How would you rate your desire to lose body fat from 1-5? (1 = not important at all; 5 = very important)
*
How would you rate your desire to gain muscles from1-5? (1 = not important at all; 5 = very important)
*
What was your weight 1 year ago?
*
What is your current weight?
*
What is your goal weight
*
Have you been on a diet before?
*
YES
NO
Please specify which diet(s) and why you think it didn’t work for you:
How compliant are you when following other programs/diets from 1-5? (1 = not compliant at all; 5 = fully compliant)
*
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Nutrition
How would you rate your nutrition habits from 1-5? (1 = very low; 5 = very high)
*
What are your nutritional goals right now?
*
Which best describes what you are doing?
*
Not eating enough vegetables
Eating too many breads / grains / crackers / granola bars
Not drinking enough water
Eating too many packaged / processed foods
Not eating enough protein
Eating too many sweets / candies / chocolate
Eating large portions at meals
Eating at restaurants / fast food too often
Skipping Meals
Drinking your calories (juice, lattes, coffee, energy drinks)
Eating fatty or deep fried foods
Time crunch - buying easy to prepare food
Other
Please list all dietary restrictions or food preferences (example: gluten-free, vegetarian, etc.).
*
Are there any foods to which you are particularly sensitive (example: cause excessive gas, bloating, stuffiness, or congestion, etc.)?
*
What are your favourite foods?
*
How would you rate your enjoyment for cooking? (1 = very low, 5 = very high)
*
Who does most of the cooking in your house?
*
Exactly how much money do you spend on groceries per month?
*
How many times per week do you shop for groceries?
*
How many meals do you eat in restaurants and/or fast food places per week?
*
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Stimulants / Sugars / Chemicals
Indicate if you are consuming any of the following:
Type a question
Coffee
Decaf coffee
Black tea
Green tea
Dairy
Fruit juice
Pop
Diet pop
Marijuana (THC)
Alcohol
Tobacco in any form
Added sweeteners
Artificial sweeteners
Are you regularly consuming any of the following? If yes, please quantify. (For example: coffee 3/day)
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Nutritional / Natural Supplements:
Please identify and list the products you are using. (Example: vitamins, minerals, herbs, enzymes, nutrition / protein supplements)
Over-the-counter / prescription medications:
Please identify and list the brands you are using. (Example: blood pressure control, cholesterol-lowering, anti-depressant, insulin management, anti-inflammatory, etc.)
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Daily Routine
Please fill out the following timetable with your most normal daily schedule listing the time you wake up, work to when you have breaks, work out, eat, attend to house chores or hobbies, and go to sleep.
What are you normally doing?
Rows
Week Day
Weekend Day
5am
6am
7am
8am
9am
10am
11am
12pm
1pm
2pm
3pm
4pm
5pm
6pm
7pm
8pm
9pm
10pm
11pm
12am
Submit
Indicate the medication name, reason for usage, and dosage
Rows
Medication
Reason
Dosage
Indicate the supplement, brand, and dosage
Rows
Supplement
Brand name
Dosage
Should be Empty: