LIFESTYLEQUESTIONNAIRE

OtherPlease provide any other notes regarding your health goals: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Thank you for filling out the Lifestyle Questionnaire. Please save a completed copy for your personal use. You can use this copy to compare your progress with a questionnaire on the final day of the program.

Health Goals1. Describe your major health, nutrition, and/or fitness goals: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

2. What are the two to three biggest barriers to achieving these goals? 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________

3. What are the two to three greatest strengths that will help you to achieve these goals? 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________

4. Please check the box that best describes how ready you are to make changes to your lifestyle to achieve these goals ⎔ Do not believe I need to change ⎔ Would like to change, but don’t think that I can ⎔ Will make changes soon ⎔ Recently started to make changes (past 6 months) ⎔ Would like to intensify changes ⎔ Made changes, but relapsed

5. On a scale of 1-10, how important is this change to you? _______

6. On a scale of 1-10, how confident are you that you will achieve this change? _______

Health Information7. How would you describe your health?⎔ Excellent ⎔ Good ⎔ Fair ⎔ Poor

8. When was the last time you visited your physician? __________

Nutrition History9. Have you ever followed a modified diet to manage a health condition?

⎔ Yes ⎔ No

If yes, please describe: _________________________________

10. Do you follow a specialized diet (low carb, gluten-free, vegan, etc.)⎔ Yes ⎔ No

If yes, please describe the diet and reasons for following: ___________________________________________________

Who purchases and prepares your food? _____________________

Physical Activity11. Are you currently physically active?

⎔ Yes ⎔ No

If yes, please describe: ____ minutes of cardiovascular activity, _____times per week ____ minutes of strength or resistance training, ____times per week ____ minutes of flexibility training, _____times per week

12. Please list your favorite physical activities: ___________________________________________________

Weight History13. What would you like to do with your weight?

⎔ lose ⎔ maintain ⎔ gain

14. What was your lowest weight in the past five years ? _______Your highest? _______

15. What is your current weight? ________________________What is your height? _________________

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lIFESTYlEQUESTIONNAIRE

gauging Your Nutrition and activity Psychological Health

Think about the past day. Have you found yourself doing any of the following? If yes, check the box and describe what happened.

⎔ justification What happened? _____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

⎔ exaggerated thinking What happened? _____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

⎔ “all or nothing” thinking What happened? _____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

⎔ unhelpful rules What happened? _____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

when you have these types of thoughts again, what will you do to help you to stay on track with your lifestyle change?

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

©2014 PoshFitness.com

LIFESTYLEQUESTIONNAIRE

Health Goals1. What are your one-month, one-year, and five-year health, nutrition, and/or fitness goals: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

2. What are the two to three biggest barriers to achieving these goals? 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________

3. What are the two to three greatest strengths that will help you to achieve these goals? 1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________ 3. _____________________________________________________________________________________________________

4. Please check the box that best describes how ready you are to permanently commit to your lifestyle change ⎔ Do not believe I need to commit ⎔ Would like to commit, but don’t think that I can ⎔ Will commit soon ⎔ Recently started to commit (past 6 months) ⎔ Would like to intensify commitment ⎔ Made commitment, but relapsed

5. On a scale of 1-10, how important is this change to you? _______

6. On a scale of 1-10, how confident are you that you will achieve this change? _______

Health Information7. How would you describe your health?⎔ Excellent ⎔ Good ⎔ Fair ⎔ Poor

8. When was the last time you visited your physician? __________

Nutrition History9. Have you ever followed a modified diet to manage a health condition?

⎔ Yes ⎔ No

If yes, please describe: _________________________________

10. Do you follow a specialized diet (low carb, gluten-free, vegan, etc).⎔ Yes ⎔ No

If yes, please describe the diet and reasons for following: ___________________________________________________

Who purchases and prepares your food? _____________________

Physical Activity11. Are you currently physically active?

⎔ Yes ⎔ No

If yes, please describe: ____ minutes of cardiovascular activity, _____times per week ____ minutes of strength or resistance training, ____times per week ____ minutes of flexibility training, _____times per week

12. Please list your favorite physical activities: ___________________________________________________

Weight History13. What would you like to do with your weight?

⎔ lose ⎔ maintain ⎔ gain

14. What was your lowest weight in the past five years ? _______Your highest? _______

15. What is your current weight? ________________________What is your height? _________________

©2014 PoshFitness.com

LIFESTYLEQUESTIONNAIRE

Questions Specific to this Lifestyle Change Program:16. On a scale of 1 to 10 how useful was this program in helping you to make a lifestyle change?

(1=not useful, 5=average, 10=extremely useful) _____________

17. Would you recommend this program to a colleague?⎔ Yes ⎔ No

18. What did you like best about this program? ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

19. How can we improve? ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Thank you for filling out the final Lifestyle Questionnaire. Please compare this copy to your copy from day one!

©2014 PoshFitness.com

sMART GoAlsSetting

Long-term SMARt goals are those specific, measurable, attainable, relevant, and time-bound goals that you hope to have achieved in the next 6 months to one year and beyond. these are the goals that you will make slow and steady progress towards achieving each time you achieve your short-term SMARt goals. the short-term goals are measured in days, weeks, and months.

EXAMPlE: i am going to eat at least seven servings per day of fruits and vegetables by the end of summer.

EXAMPlE: i am going to lose 30 pounds in the next year by exercising at least 20 minutes most days of the week and only eating a dessert once per week.

EXAMPlE: i am going to break the cycle of emotional eating within the next six months by eating every meal at the kitchen table without any distractions.

loNG TERM GoAlnutrition goal:

#1. ____________________________________________________________________________________________________

Physical activity goal: #1. ____________________________________________________________________________________________________

Behavioral goal: #1. ____________________________________________________________________________________________________

sHoRT TERMnutrition goal:

#1. ____________________________________________________________________________________________________

Physical activity goal: #1. ____________________________________________________________________________________________________

Behavioral goal: #1. ____________________________________________________________________________________________________

©2014 PoshFitness.com

Domain Barriers SupportsIndividual

Interpersonal

School

Community

Public Policy

Now, identify what you think overall will be the 2 biggest barriers to you sustaining your lifestyle change. Describe how you might use your supports and other tools to overcome them.

1. _____________________________________________________________________________________________________ 2. _____________________________________________________________________________________________________

TakINg THE BIg VIEWBARRIERS TO AND SUPPORTS FOR LIFESTYLE CHANGE

Looking at this graphic, identify barriers and supports for your lifestyle change within each domain:

INDIVIDUal —(knowledge, attitude, skills)

INTERPERSoNal —(social network)

SCHoolS—(environment, ethos)

CoMMUNITY—(cultural values, norms)

PUBlIC PolICY