Personal Health Assessment

Personal Health Assessment
Full Name *

First Name Lasst Name
Gender *

Male Female
Age *
years
Height *
cm
Weight *
KG
E-mail *
Phone Number ( optional, but helpful )

- Area Code Phone Number
In general how would you rate your overall health?

Excellent Good Fair Poor
What 's your activity level during the day? *

sedentary (seated only) Moderate (light activity such as walking) High ( very active)
Please list the physical activities that you participate in?
Are you currently excersising regulary (at least 3x per week)? *

Yes No
Have been diagnosed with diabetes or high blood pressure? *

Yes No
Your current diet could be best characterized as: *

low-fat low-carb high-protein Vegetarian/Vegan No special diet
How many meals a day do you eat? *

3 meals a day: breakfast, lunch and dinner 3 + meals per day: breakfast, lunch, dinner and snacking 2 : ( skip breakfast ) lunch and dinner Only when hungry
How many hours apart between meals do you eat? *

1 hour 2 hours 3 hours 4 hours It depends.. eat only when hungry
Which of the following best describes your goals? *

1. Improved health and Nutrition 2. Weight Loss and Exercise 3 . Other ( please list )
If you checked the box "other " above please list

Please select your motivational level to reach your goal

	1	2	3	4	5
Worst						Best

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