Lifestyle Assessment Questionnaire

Name *

First

Last

Contact number *

Email *

1) I eat mostly food from which category? *

Category A Foods — I eat mostly food from this category: Whole grains (cooked oats, 2+ grains cooked cereal blends, 100% wheat, quinoa, millet, brown rice, wild rice, rye, etc.). Also, whole fruit (berries, apples, pears, figs, dates etc.), nuts (pecans, walnuts, almonds etc.), seeds (flax, chia, pumpkin, sunflower etc.), beans (lentils, black, chickpeas, kidney etc.), water as the beverage of choice, and a variety of colorful vegetable.
Category B Foods — I eat mostly about 1/2 of my food choices from category A and 1/2 of my food choices from category C.
Category C Foods — I eat mostly foods from this category: Refined grains (fiber removed) such as white rice, bread and pasta and refined cornmeal, fruit juice, sugar sweetened drink, alcohol, dairy, eggs, rich desserts and pastries, “junk foods”, fish, poultry, beef, processed packaged meals and small amounts of fruit & vegetables.

2) On average, how many servings of fruit and vegetables do you eat every day? 1 serving = ½ cup chopped fruit, grapes or non-leafy vegetables or 1 medium size whole fruit such as an apples, oranges, pear or tomato, or 1 cup leafy greens such as lettuce, collards, kale or spinach. *

3) How many days a week do you snack between meals? *

4) What is your largest meal of the day? *

Breakfast
Lunch
Dinner

5) How many days a week do you exercise? *

6) How many minutes are your exercise sessions? Include highly physical jobs and gardening. *

7) How many cups of water, herbal tea or water added to a smoothie do you drink a day? *

8) How many days a week do you spend at least 30 minutes out in nature? *

9) How many nights a week do you get 7 or more hours of restful sleep? *

10) How well are you coping with the stressors of everyday life? *

11) What level of happiness would you rate yourself currently? *

12) How would you describe your current health status? *

13) How would you describe your energy level over the past month? *

14) How would you describe your levels of body aches or pain over the past month? *

15) How many different medications do you take daily? For 6 or more circle the zero. *

16) Your height (feet & inches)

16) Your weight (pounds)

16) Your BMI

17A) FEMALE ONLY. Waist

17B) MALE ONLY. Waist

18) Blood pressure - Systolic

18) Blood pressure - Diastolic

19) Resting heart rate (bpm)

YOUR HEALTH LIFESTYLE SCORE (TOTAL)

101+ Excellent - 81-100 Very Good - 61-80 Average - 41-60 Below Average - 21-40 Poor - 20 or less Very Poor