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Step 1: General Health
1. Age
2. Gender
Male
Female
3. Height in Feet
2
3
4
5
6
7
4. Height In Inches
0
1
2
3
4
5
6
7
8
9
10
11
5. Weight
6. BMI
Step 2: Healthy Choices
1. How often do you visit your doctor? Check no more than two
When you feel something is not right
Annually as a preventative measure
Never
Only when you are really sick
2. Do you smoke?
Yes
Occasionally
No
3. How many alcoholic drinks do you consume a day?
0
1-2
3-4
More than 4
4. How many drinks containing caffeine do you consume a day?
0
1-2
3-5
More than 5
5. Choose the answer that best describes your daily consumption of water
I drink at least 8 glasses of water each day
I average about five to six glasses on most days but I sometimes get eight.
I don't drink much water.
6. How many hours of sleep do you average per night/day?
Less than 5
5-6
6-7
7-9
More than 9
7. Do you participate in yoga, meditation exercises or other types of stress relief?
Yes
No
Occasionally
Step 3: Healthy Diet
1. Choose the answer that best describes your daily consumption of whole grains
I don't eat many whole grains. It's mostly white bread, white pasta and any breakfast cereal that's easy.
I generally eat two or three servings of whole grains like whole-grain bread, oatmeal, other cereals labeled "whole grain" or wild/brown rice each day.
I easily eat more than three servings of whole grains like whole-grain bread, oatmeal, other cereals labeled "whole grain" or wild/brown rice each day.
2. Choose the answer that best describes your daily consumption of vegetables
I don't like vegetables but I eat a few because I know its good for me.
I generally eat about two cups of vegetables each day but not always the dark green vegetables like I should.
I love vegetables and easily eat 2 cups each day. I also try to get a couple of servings of dark green vegetables like broccoli or spinach each week.
3. Choose the answer that best describes your daily consumption of fruits
I eat at least 2 pieces (or cups) of fruit each day and I try to keep my juice intake to less than half of my total fruit each day.
I generally have one piece (or cup) of fruit each day but I tend to drink more fruit juice than actual fruit.
I'll have a piece of fruit every once in a while, but it's not my favorite
4. Choose the answer that best describes your daily consumption of proteins
I eat about 6 ounces of lean protein like lean meat, chicken without the skin, fish, beans or tofu each day.
I probably eat more than 6 ounces of lean protein like lean meat, chicken without the skin, fish, beans or tofu each day.
I eat as much protein as I like each day; and I tend to like fatty meats; cold cuts; sausage as well as dark meat chicken, skin and all.
5. Choose the answer that best describes your daily consumption of milk products
I rarely or never consume dairy products
I choose only regular milk and/or full fat items in the dairy category.
I probably have 1 or 2 cups of fat-free or low-fat (1%) milk, yogurt or cottage cheese each day.
I have 3 cups of fat-free or low-fat (1%) milk, yogurt or cottage cheese each day.
6. Choose the answer that best describes your weekly consumption of seafood
I don't like seafood
I try to eat seafood, especially oily fish like salmon, once a week.
I love seafood and try to eat oily fish, like salmon, at least twice a week.
7. Choose the answer that best describes your weekly consumption of beans and lentils
Each week I eat at least 3 cups of beans, peas, lentils or split peas in salads,chili, soups.
Each week I try to eat some beans, peas, lentils in salads, chili, soups.
I don't think about whether I eat beans, peas, lentils or split peas
8. Choose the answer that best describes your daily consumption of foods with oils
I watch my intake of added oils from salad dressing, sauces and cooking (no more than 2 oz a day) and I use vegetable oils like olive or canola whenever possible .
I try to watch my intake of added oils in salad dressing and sauces, but I'm not really sure how much it is. I know I use vegetable oils like olive or canola whenever possible .
I don't pay attention to the type or the amount of added oils I eat every day.
9. Choose the answer that best describes your consumption of fiber
I don't track how much fiber I eat.
I try to eat foods with more fiber each day.
I try to eat at least 32 grams of fiber each day.
10. Choose the answer that best describes your consumption of salt
I limit the salt I use in cooking, and I read food labels carefully to limit other sources of salt and sodium whenever I can.
I try to limit the salt I use in cooking, and I sometimes read food labels to limit other sources of salt and sodium when I remember.
I always use salt in cooking, and I don't think about how much salt or sodium I consume.
11. Choose the answer that best describes your consumption of added sugars
I choose and prepare foods and beverages with little added sugar or caloric sweeteners
When I remember, I try to choose and prepare foods and beverages with little added sugar or caloric sweeteners. .
I eat a lot of sugary foods and drink quite a few sugary beverages..
12. Please check those that best apply to you.
I eat a lot of processed foods like chips and frozen dinners daily
I know I eat too much fatty food like red meat and cream cheese, but that's what I like to eat
I know cholesterol-rich foods like eggs, cheese and dark meat poultry should be eaten in moderation, but I tend to eat them several times a day.
I do a fairly good job of avoiding processed foods. I watch what I eat when it comes to cholesterol rich dishes and I try to avoid fatty foods like whole milk and fatty meat.
Step 4: Supplements
1. Do you take a multivitamin?
Yes
No
2. How often do you take your multivitamin?
Daily
Several times a week
When I feel the need
I don't take one
3. How do you typically take your multivitamin?
With food
On an empty stomach
I don't take one
4. Do you take other dietary supplements?
Yes
No
5. Which other supplements do you take? Check all that apply
None
Vitamin A
Vitamin B/B Complex
Vitamin C
Vitamin D
Vitamin E
Calcium
Magnesium
Zinc
Echinacea
Garlic
Ginkgo Biloba
Ginseng
Green Tea
Saw Palmetto
St. John's Wort
Valerian
Coenzyme Q10
Glucosamine + Chondroitin
Lutein
Lycopene
Fish Oil
Flax Seed/Oil
Sports Nutrition Supplements
6. What are the main reasons you take supplements? (check all that apply)
General health
Particular condition
Energy
Weight management
To increase muscle mass
To augment diet
To supplement a poor/marginal diet
Because I think it's the smart thing to do
I don't take supplements
7. Do you ever take more than the label recommends?
Never
Sometimes
Most of the time
I don't take supplements
8. Where do you get information on supplements?
Doctor
Nurse
Pharmacist
Dietitian/ Nutritionist
Salesperson
Family
Friends
Internet
TV, Radio, Newspapers, Magazines
Nowhere
Step 5: Exercise
1. How would you classify your exercise regimen?
I don't have one
I try to exercise 2 - 3 times per week
I exercise at least 4 to 5 times per week and sometimes more
I exercise for at least an hour every day
2. Choose the answer that best describes the length of your exercise routine
No exercise
30 minutes
1 hour
2 hours
3. What type of exercise do you do? Check all that apply
No exercise
I enjoy cardiovascular exercise like running, walking, aerobics, dancing, tennis or basketball
I enjoy recreational activities like golfing, softball, fishing or camping
I enjoy lifting weights and other strength training activities
My day is not complete without a yoga or pilates class
4. How often do your change exercise routine?
I try to work out on a regular basis, but life and work often prevent me from exercising like I should
I stick to the same routine because it works for me
I like to change my exercise routine on a regular basis just to keep it interesting
I change my workout on a regular basis in order to improve my performance
5. What do you do to increase your movement during the day?
Nothing
I take the stairs instead of the elevator at work
I park away from the grocery store and the mall to increase my walking
I walk around the office a lot instead of using e-mail
I try to stay active around the house and in the yard, especially on weekends