|
First Name:
|
|
|
Surname name:
|
|
|
Gender?
|
Female
Male
|
|
Where do you live?
|
|
|
Which State do you live in?
|
|
|
Email Address:
|
|
|
What is your contact phone number?
|
|
|
Would you like me to call you with the results?
|
Yes
No
|
|
Do you have any specific health and wellness goals?
|
|
|
What is your height?
|
|
|
What is your weight?
|
|
|
If you are a female, is your waistline greater than 80 cm (35")?
|
Yes
No
Do not know
|
|
If you are a male, is your waistline greater than 94 cm (40")?
|
Yes
No
Do not know
|
|
What is your age?
|
|
|
To be your ideal weight, do you need to ….
|
Lose
Maintain
Gain
|
|
If you need to lose/gain weight, how much weight do you need to lose/gain?
|
|
|
Have you tried any weight loss programs in the past?
|
YES
NO
|
|
On a scale of 1 – 10, with 10 being the most serious, how serious are you about losing or gaining weight?
|
1
2
3
4
5
6
7
8
9
10
|
|
Which of the following health conditions are of concern to you?
|
|
|
Do you eat more meals with poultry, lean meat, fish and plant (soy) proteins rather than steaks, roasts and other red meats?
|
YES
NO
|
|
Do you eat a variety of colourful fruits and vegetables and do you eat at least five servings a day of these?
|
YES
NO
|
|
Do you consume primarily whole grains (100% whole wheat bread and pasta, brown rice) rather than regular pasta, white rice and white bread?
|
YES
NO
|
|
Do you eat ocean-caught fish at least 3 times a week?
|
YES
NO
|
|
Do you avoid the intake of fried foods, dressings, sauces, gravies, butter and margarine?
|
YES
NO
|
|
Is your digestive system free of indigestion or irregularity?
|
YES
NO
|
|
Do you get a minimum of 30 minutes of exercise 3 – 5 days a week?
|
YES
NO
|
|
Do you maintain a stable and appropriate weight?
|
YES
NO
|
|
Do you usually have time to prepare balanced meals, rather than take out or eating on the run?
|
YES
NO
|
|
Do you resist the urge to eat typical snack foods (chips, chocolates, etc) throughout the day and after dinner?
|
YES
NO
|
|
Are you free of water retention and bloating?
|
YES
NO
|
|
Do you have energy and focus you need to meet your daily challenges?
|
YES
NO
|
|
Do you drink at least 8 glasses of water a day?
|
YES
NO
|
Are you getting your daily recommended allowance of Calcium?
a. Men = 1,000mg
b. Women under 50 = 1,000mg
c. Women 50 and older = 1,300mg
|
YES
NO
DO NOT KNOW
|
|
Are your blood pressure, triglycerides and bad cholesterol levels in the normal range?
|
YES
NO
DO NOT KNOW
|
MEN:
Are you free from problems associated with your prostate such as slow urination or waking up at night to urinate?
|
YES
NO
|
WOMEN:
Are you free from problems associated with your menstrual cycle/menopause such as mood changes, hot flushes or problems sleeping?
|
YES
NO
|
|
|
