1 Check the Following Statements That Apply:qOccasionally or frequently skip mealsq Suffer from fatigueq Currently overweightq Crave sweets or carbohydratesq Crave stimulants, such as caffeine or soft drinksq Suffer from chronic painq Suffer from headachesActivity Level Check Your Current Level of Work or Lifestyle:qLevel 1 Very Light Work:Sitting, standing,driving, reading, computer, 2 Light Work:Light housework, labor,childcare, mechanic, some sitting, 3 Moderate Work:Heavy gardening,housework, labor, no sitting, 4 Heavy Work:Heavy manual labor,construction, digging, Level Check Your Current Level of Exercise:qNoneqLevel A Light Exercise:1-3 times per week,easy pace, stretching, walking, B Moderate Exercise:2-3 times per week, moderate pace, some weights, C Heavy Exercise:3-4 times per week,vigorous pace, weights, fast running, Frequency Check Which Apply:qSkip breakfast or other meals_____qThree meals/dayqTwo meals/dayqOne meal/dayqGraze-small frequent meals (how many/day) _____qGenerally eat on the runExercise Frequency and Schedule Check Which Apply:q5-7 days per weekq3-4 days per weekq1-2 days per weekq45 min or more duration per workoutq30-45 min or more duration per workoutqLess than 30 min qUse of personal trainerqMember of fitness clubqOwn exercise equipmentqWalk: days/week _____ _____qRun, jog, jump rope, other aerobic: days/week_____qWeight lift: days/week_____ _____qStretch: days/week_____ _ _ _____qYoga: days/week_____ _ _qOther_____ days/week_____ _ _Healthy Living QuestionnaireBalance Eating Check Which Apply:qMixed food diet (animal and vegetable sources)qVegetarianqVeganqSalt RestrictionqFat RestrictionqStarch/carbohydrate restrictionqThe Zone DietqTotal calorie restrictionqSpecific food restrictions of.
2 Qdairy qwheat qeggsqsoy qcorn qall glutenqOther_____Servings per day:Fruits (citrus, melons, etc.)_____Dark green or deep yellow/orange vegetables_____Grains (unprocessed)_____ _Beans, peas, legumes _____Dairy, eggs_____ _ __ _ _ _____Meat, poultry, fish_____ 2002 Wellness Watchers International, :_____ Gender:q Maleq FemaleCurrent Weight: _____Do you consider yourself:q underweight qoverweight qjust right Unintentional weight loss or gain of 10 pounds or more in the last three months: Yes qNo qRecent changes in your ability to:qsee qhear qtaste qsmell qfeel hot/cold Name:_____ Date: _____Stimulant Use Habits Check Which Apply:qTobacco:Cigarettes: #/day_____Cigars: #/day_____Pipe: #/day_____qAlcohol:Wine: # glasses/day or week_____Liquor: # ounces/day or week_____Beer: # glasses/day or week_____qCaffeine:Coffee: # of 6 oz cups/day _____Tea: # of 6 oz cups/day _____ _ _ _Soda w/caffeine: # of cans/day _____Soda w/o caffeine: # of cans/day _____Other sources_____qWater.
3 # glasses/day _____Stress Habits Check Which Apply:Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 1 2 3 4 5 6 7 8 9 10Is your job associated with potentially harmful chemicals,pesticides, radioactivity or solvents: Y qN qDo you suffer from insomnia/sleep disorders? Y qN qDo you often abruptly awake from sleep? Y qN qDo you suffer from depression/mood swings? Y qN qSupplement Use Habits Check Which Apply:qMultivitamin/mineralqVitamin Cq Vitamin EqEPA/DHAqGLA (Evening primrose)qCalcium, source_____qMagnesiumqZincqMinerals, describe_____qFriendly flora (acidophilus)qDigestive enzymesqAmino acidsqCoQ10qAntioxidants (lutein, resveritol, etc.)qHerbs teasqHerbs extractsqChinese herbsqAyurvedic herbsqHomeopathyqBach flowersqSuperfoods (bee pollen, phytonutrient blends)qLiquid meals (Ensure)qOther_____Energy VitalityI d like to:qHave more energyqHave longer enduranceqHave more motivationqSleep betterqBe less tired after lunchqFeel more vitalqRegain vitality and vigor of my younger yearsqGet less colds and fluqGet rid of allergiesqNot use so many over the counter drugsqStop using laxativesqBe free of pain Longevity Life EnrichmentI d like to:qReduce my risk of degenerative diseaseqSlow down accelerated agingqMonitor biomarkers of agingqHave less facial wrinklesqMaintain a healthier life longerqChange from a treating-illness orientation to a creating Wellness lifestyleBody Composition Fat/MuscleI d like to:qBe strongerqBe thinnerqBe more muscularqBurn more body fatqBe more flexibleqLose weightStress Reduction Mental/Emotional I d like to.
4 QBe happierqBe less depressedqBe less moodyqBe less indecisiveqBe more focusedqThink more clearlyqImprove my memoryqLearn how to reduce stressqLearn how to meditate COMMENTSH ealthy Living Questionnaire ~Page 2 2002 Wellness Watchers International.