Women’s Lifestyle Assessment

Answer each question thoughtfully, take your time, and of course, there are no right or wrong answers. This is all about you and the more you can tell me, the better able I’ll be to give you some guidance.

The answers should be based on how you feel and are experiencing things today, not how you’d like to do things but honestly how you do your day-to-day.

There are 3 categories;

There is room at the bottom for you to include anything you think is important for me to know that I didn’t ask about.

If you'd prefer to hand-write this assessment and return it to me by fax, please click here to print this page, then fax your completed assessment to (631) 728-2456.
To complete the Lifestyle Assessment online, fill in form fields for all sections below, then click the button at the end of the page to submit your responses.
Your Name:                     E-mail Address:   
FOOD
Do you eat breakfast?   
Yes No
If so, what do you eat? Give examples, you don’t have to write everything you might eat, just what you generally have. (Ex: eggs and fruit, cereal, coffee only, juice and vitamins etc.)
How long after rising do you eat or drink something?  
Coffee or Tea?   
Coffee Tea Other
If you use sweetener, what is it?  
If you use dairy in the above, what is it?  
Do you get hungry between meals? 
Yes No
If you snack, what is a typical one?   
How many times per day do your meals include a starch such as potatoes, bread or rice? 
How many servings of fruit do you eat on average per day?  
How many servings of vegetables do you eat on average per day? 
What sorts of foods make you feel the best after eating? (Ex: steak and fish, potatoes and pasta, salads, fruits, or combination of all things)
Do you notice you are tired after a certain type of meal?
Yes No
If so what is in that meal?  
What time do you eat dinner on average?  
Please check all that apply:
I'm a soda person
I'm a diet soda person
I am a vegetarian
I love bread of all kinds
I love pasta
I love carbs in general
If you are a soda person, how many per day?  
Do you like sweets?  
Yes No
If yes, what's your poison and how often do you partake?
If you eat low or non fat foods what types?
Is there anything you don’t eat categorically such as meat, eggs, diary, wheat etc?
Which do you crave? (Check all that apply):    Salt      Carbs      Sugar      Alcohol
Are you hungry regularly?  
Yes No
Do you have any idea how many calories you take in right now?  
Anything else you want me to know about your food choices?
MOVEMENT
Do you get any exercise on a regular basis, if yes, please describe.
Do you enjoy exercise or is it work to you?
Are you seated most of the day at a computer or are you on your feet most of the day?
Do you have any restrictions on movement such as an injury or chronic pain?
If you don't do much movement is there anything that will prevent you from adding it in to your day?
LIFESTYLE FACTORS
Do you feel you need to lose weight?   Yes   No    
If yes, please answer the following:  do you have a goal?
Are you a scale person?  Yes   No    
If so how often do you like to weigh in? 
Have you lost weight before?  Yes   No  
If yes, what programs or plans did you use then?
Please check all that apply:
I like to cook and follow recipes
I like to count my calories or carbs
I Hate to cook but I shop well
I want to eat healthy but don't have the time
I’m good with a plan that I can follow
I know what I should eat but I just don't do it
I want guidelines not law
I rely on convenience meals
I'm a type A
I occasionally eat convenience meals
I'm an easy going person
I am open to making the changes necessary to help me feel my best
I go to an office for 8 hours or more per day
It’s just me to cook for
I work from home
I cook for others
How often do you eat out each week? 
I’ll never find time in my schedule to include exercise and or cooking
I will do what it takes to make time for some exercise and better eating habits
I do drink alcohol
If you do drink alcohol, what’s your poison, and how many per week please? (Don’t worry, I’m not judging or taking it away)
I fall asleep on the couch at night
I sleep well
My sleep is more or less fine
I don’t sleep well
I smoke cigarettes:  Yes   No             If so, how many per day? 
I have the following symptoms (check all that apply):
Hot Flashes
Mood swings -- worse than normal
Night time anxiety
Dry Skin
Heart Palpitations
Thinning Hair
Moodiness
Weight Gain
Fatigue
Other: 
Do you use any form of hormone replacement or The Pill?  Yes   No
 If yes, please describe:
Please list any supplements you take and medications:
Do you get an annual physical? Yes   No
If so are you current on all of your tests? Yes   No
Are you happy with your doctor(s)? Yes   No   Sometimes
 What is your biggest complaint or where are you most dissatisfied with your body or lifestyle right now?
Anything you'd like to tell me about how you approach your day, life etc as it relates to feeling good?
Please feel free to write down anything you think will be important for me to know in order to get a sense of you, your day, as it relates to making improvements in how you feel.
 
 
You're almost done... don't forget to click the button below to submit your completed assessment. Once I have received your responses I will contact you by e-mail to set up our one-hour strategy session.
 
Midlife With A Vengeance    |    (631) 728-2456
www.midlifewithavengeance.com    |    Gregory@midlifewithavengeance.com