Lifestyle Assessment

Personal data

If you suffer from any of the following, please tick if applicable:

1. Fitness & Movement

Do you consider yourself an active person?
Do you enjoy exercise?
Does this statement apply to you? “Right now, I’m not in shape and I don’t know how to get started, to improve.”
Does the following statement apply to you? “I don’t exercise because I’m afraid of getting hurt.”
I always have enough energy to exercise?
Is the reason you exercise, or need to exercise, vividly clear in your mind ?
Do you usually feel motivated to exercise?
Do you consciously look to take the active option such as taking stairs rather than lifts?
What % of a normal day do you spend sitting down or being inactive?
Do you find alternative ways of staying active when your regular routine is compromised due to external factors such as poor weather or being on holiday?
Besides from ‘breathless exercise’ on how many days per week do you achieve more than 30 minutes of ‘natural movement daily?’ (Walking, gardening, DIY, housework…)
Do you monitor your active steps with a pedometer? If so on how many days would you achieve 8,000 steps or more.
How many times per week do you exercise until you are breathing heavily for at least 30 minutes?
How many times per week do you engage in muscle stretching exercises such as yoga, Pilates or tai chi?
Do you consciously try to include strength exercise into your weekly exercise routine?
Do you adapt your exercise program to current recommendations on the basis of a health condition?

Summarising the last 6 weeks on a scale of 5 (strongly agree) to 1 (strongly disagree), please rate the following:

2. Clinical Nutrition

Is food and the enjoyment of food a big part of your life?
Do you enjoy preparing and cooking food
Do you feel you have a good understanding of what ‘healthy eating’ means?
Do you eat between meals?
Do you eat pre-prepared foods? (frozen foods, pizza, Italian or Chinese food, packaged rice and pasta sides…)
How often do you eat out? (sandwiches, fast food, pizza, barbecue, Chinese food…)
Do you read the nutrition facts table on food labels?
How do you perceive your weight at present?
What is your dominant food source?
If you overeat on a particular day how do you react afterwards?
How often do you experience cravings or impulsive eating?
Do you eat organic and/or locally produced food?
Do you regularly eat slowly and/or not at a table?
Do you regularly experience skin issues such as eczema or dry skin linked to your eating?
Do you regularly experience unexplained bloating, flatulence or digestive discomfort linked to your eating?
How many vegetables do you eat per day? 1 portion = 1 average vegetable, ½ cup fresh, frozen or canned vegetables, 1 cup lettuce, ½ cup vegetable juice
How much fruit do you eat per day? 1 portion = 1 average fruit, ½ cup fresh, frozen, canned or pureed fruit ½ cup fruit juice
How big is your meat/alternative protein portion per meal? 1 portion = 100g or 3 ounces or the equivalent of the palm of your hand.
How many portions of oily fish do you eat per week?, salmon, mackerel, anchovies etc
How often do you eat unbreaded fish? Excluding oily fish. Tuna, cod, etc.
What kind of dairy products (milk and yogurt ,cheese) do you eat?
What kind of fats do you usually use for cooking
What kind of fats do you usually use as a spread, potatoes, sauces…)
On average what proportion of your plate is filled by grains or starches? (bread, pasta, rice, couscous, potatoes…)
Do you select whole grain products? (whole grain bread, high-fibre breakfast cereals, brown rice…)
How often do you eat baked products? (doughnuts, buns, croissants, danish pastries, muffins).
How often do you eat store-bought desserts? (as a snack or after a meal, biscuits, regular ice cream, cakes, pastries, pies, etc.)
How often do you eat sweets or sugar rich foods (chocolate, table sugar, honey, jam…)
Do you drink sweet drinks? (fruit juice or fruit drinks, soft drinks or energizing drinks, iced tea, lemonade…)
Do you drink artificially sweetened drinks, Diet Coke, Pepsi Max, etc
Do you eat salted foods? (crackers, crisps, pretzels, salted nuts or seeds, etc.)
Do you add salt to your food?
How many portions of processed red meat (burgers, sausages, bacon etc) do you eat per week?
How many nights per week would you have an alcoholic drink?
What is your average weekly alcohol consumption? 1 drink = 5 oz of wine, 1 beer, 1½ oz of spirits
How many caffeinated drinks do you have per day? (Please include non-herbal tea and diet drinks. )
What time of day is your last caffeinated drink?
How many 500 ml/1/2 pint glasses of water do you drink a day?

Summarising the last 6 weeks on a scale of 5 (strongly agree) to 1 (strongly disagree), please rate the following:

3. Energy Recovery

Do you feel you have enough energy?
Do you believe energy levels are associated with ageing?
Over the past 4 weeks how often have you felt tired or without ‘normal energy’ ?
Are you over demanding of yourself and prone to ‘setting the bar too high’?
To recharge when tired I collapse in front of the TV
Do you feel too tired to look after yourself?
Do your good habits fade when you are frustrated, disappointed, discouraged or angry?
Does boredom influence your ability to sustain good habits?
Do your emotions influence how healthily you eat?
Do you reward yourself by eating junk food?
I eat quickly, not at a table and whilst working.
Does eating something you feel you shouldn’t have a lasting impact on your good habits?
Is your general mood low and not what you want it to be?
Do you regularly (more than 1 per season) pick up colds, viral infections or whatever is going around?
Do you sleep badly and wake unrefreshed?
Do you sleep well but seem to wake unrefreshed?
Do you have irregular bed and wake times?
Do you snore at night?
Is your sleep regularly interrupted by factors outside of my control?
Do you always use tv/tablets/phones within 1 hour of going to bed?
Do you meditate ?
I have a stressful life but fell that I cope well.

Summarising the last 6 weeks on a scale of 5 (strongly agree) to 1 (strongly disagree), please rate the following:

4. Managing Ageing

Do you make conscious choices to help slow down the ageing process??
Do you believe that controlling your health now will influence your risk for chronic disease or longevity?
I feel putting the effort into my nutrition and exercise will benefit me in the future?
Do you take saunas? Infrared or traditional. ?
Are you aware of the presence of environmental toxins in your life? (chemicals, pesticides, heavy metals, fumes) ?
Do you regularly do a detox programme?
Do you mainly drink mineral or filtered water?
Do you use self-tan products?
Do you use the sun bed?
Do you regularly apply sun cream on sunny days?
Do you use anti-ageing skincare products?
How often do you travel by aeroplane per year?
Do you have any amalgam fillings?
Do you live within 100m of a major road?
Do you smoke or have you been a regular smoker in the last 6 months?
Do you dye your hair regularly?

Summarising the last 6 weeks on a scale of 5 (strongly agree) to 1 (strongly disagree), please rate the following: