Readiness For Change

Name*

First Last

Email*

Phone*

Do you look in the mirror and feel Frustrated, upset, or humiliated because of how your body looks?*

Yes (+3)

I'm not sure (0)

No (-3)

When you feel run down and tired, what do you think is the source of these feelings?*

Getting older (-1)

My lifestyle choices (+3)

Something else altogether (-3)

Are you taking any medications for heart disease, high blood pressure, or type Il diabetes that you didn't have to take when you were younger?*

Yes, I'm on two or more of these medications (+3)

Yes, I'm on only one of these medications (+1)

No, I'm not on any of these medications (-3)

If your fitness has deteriorated over the years, how do you explain the fact that you're in worse shape than when you were younger but haven't changed your habits at all?*

I think it's my family history (-1)

I think it's that I'm less active (+3)

I think it's a natural consequence of aging (-1)

I don't know why it's happening (0)

If you don't have anyone to exercise with regularly, are you willing to look for a physical activity partner?*

Yes (+5)

No (-5)

Are you willing to join a gym today?*

Yes (+5)

No (-5)

If someone told you that you'd need to throw away all the foods in your cupboards today and go shopping for different foods that are more appropriate to your goal, would you do it?*

Yes (+3)

No (-3)

If an expert presents some information on diet and exercise that contradicts what you currently believe, what approach will you take?*

keep an open mind and give it a try (+3)

Ask a friend (O)

Ignore the advice (-3)

Are you willing to have a meeting with your friends and loved ones and share your behavior goals and desired outcomes with them?*

Yes, right away (+5)

Yes, but not just yet (-3)

No (-5)

If your work environment presents significant barriers to you exercising and eating well, would you consider speaking to your employer about changing some of these conditions or are you willing to find new employment?*

Yes (+5)

No (-5)

Are you ready to spend less time with people who offer little or no social support for your goals while spending more time with those who do offer support?*

Yes (+5)

No (-5)

If a friend or loved one suggests that you don't have what it takes to get into great shape because you've failed before or for some other reason, what will be your response?*

I can do it (+2)

I know I've got to make some changes but I'll take it one day at a time (+5)

Maybe I can't do it (-5)

Are you willing to wake up in the morning a bit earlier and stay up at night a bit later to accomplish your goals?*

Yes (+5)

No (-5)

Are you willing to slowly work up to five hours of physical activity each week?*

Yes (+5)

No (-5)

How would you rate your quality of sleep out of 10?*

10 = great. 1 = poor

Do you have trouble getting to bed at night?*

Is your sleep broken?*

How many hours do you get of sleep each night?*

What foods did you eat often as a child?

Recall as best as you can

Breakfast*

Lunch*

Dinner*

Snacks*

Liquids*

What is your food like these days?

Describe an average day

Breakfast*

Lunch*

Dinner*

Snacks*

Liquids*

Will family and/or friends be supportive of your desire to make food and/or lifestyle changes?*

Yes

Do you cook?*

Yes

What percentage of your food is home cooked?*

Please enter a number from 0 to 100

Where do you get the rest from?*

Do you crave sugar, coffee, cigarettes, alcohol or have any major addictions?*

Yes

Are you willing to commit to the process for the next 6 months?*

Yes

The most important thing I should change about my diet to improve my health is*

Anything else you would like to share?*

Phone

This field is for validation purposes and should be left unchanged.