Personal Health Assessment

Personal Health Assessment
Full Name*

First NameLasst Name
Gender*

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

Area CodePhone Number
In general how would you rate your overall health?

ExcellentGoodFairPoor
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)?*

YesNo
Have been diagnosed with diabetes or high blood pressure?*

YesNo
Your current diet could be best characterized as:*

low-fatlow-carbhigh-proteinVegetarian/VeganNo special diet
How many meals a day do you eat?*

3 meals a day: breakfast, lunch and dinner3 + meals per day: breakfast, lunch, dinner and snacking2 : ( skip breakfast ) lunch and dinnerOnly when hungry
How many hours apart between meals do you eat?*

1 hour2 hours3 hours4 hoursIt depends.. eat only when hungry
Which of the following best describes your goals?*

1. Improved health and Nutrition2. Weight Loss and Exercise3 . 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

1 is Worst, 5 is Best