Your Personal Wellness Evaluation Form
 
             
       
*Required Entries
Contact Information

First Name*:  Last Name:

Email*:  Birth Date:

City:   State/Province:    Zip:

Phone* (numbers only):    Best time to call:

Wellness Coach Email Address*:                     Wellness Coach Name:
      

Height (in.):   Weight (lbs):   Age:   BMI*†:

†Calcluate your BMI from the calculator on this page and enter it here.

Wellness Questionaire

Question 1:                                                                          yes    no
Do you eat more meals with poultry, lean meat, fish and plant
(soy) proteins rather than steaks, roasts and other red meats?   

Question 2:                                                                           yes    no
Do you eat a variety of colorful fruits and vegetables and do
you eat at least seven servings a day of these?

Question 3:                                                                           yes    no
Do you consume primarily whole grains (100% whole wheat
bread and pasta, brown rice) rather than regular pasta, white
rice and white bread?

Question 4:                                                                           yes    no
Do you eat ocean-caught fish at least 3 times a week?

Question 5:                                                                           yes    no
Do you avoid the intake of fried foods, dressings, sauces,
gravies, butter and margarine?

Question 6:                                                                           yes    no
Is your digestive system free of indigestion or irregularity?

Question 7:                                                                           yes    no
Do you get a minimum of 30 minutes of exercise 3-5 days
a week?

Question 8:                                                                           yes    no
Do you maintain a stable and appropriate weight? 

Question 9:                                                                           yes    no
Do you usually have time to prepare balanced meals, rather
than take out or eating on the run?

Question 10:                                                                         yes    no
Do you stay away from soda and typical snack foods
throughout the day and after dinner?

Question 11:                                                                         yes    no
Are you free of water retention and bloating?

Question 12:                                                                         yes    no
Do you have the energy and focus you need to meet your
daily challenges?

Question 13:                                                                         yes    no
Do you drink at least 8 glasses of water a day?

Question 14:                                                                         yes    no
Are you getting your daily recommended allowance of Calcium?
a. Men = 1,000mg b.Women under 50 = 1,200mg
c.Women 50 and older = 1,500mg

Question 15:                                                                         yes    no
Are your blood pressure, triglycerides and cholesterol in the
normal range?

Question 16a (Men):                                                              yes    no
Are you free from problems associated with your prostate
such as slow urination or waking up at night to urinate?

Question 16b (Women):                                                         yes    no
Women:Are you free from problems associated with your
menstrual cycle/menopause such as mood changes, hot
flashes or problems sleeping?

Your Wellness Coach will analyze your answers and email or call you about your Wellness Evaluation and recommend a personalized program to meet your health and wellness needs.
 
Weight: lbs.
Height: Ft. In.
Body Mass Index
 

According to the Panel on Energy, Obesity, and Body Weight Standards published by American Journal of Clinical Nutrition, your category is:
   
 
The Keys to Wellness

Every day we search for ways to feel better; this makes our days more enjoyable for ourselves as well as those around us. The recipe for success is a balanced diet combined with sufficient water intake, along with exercise. By combining these three keys to daily wellness, you are giving yourself the opportunity to feel good day after day.
 
 
           

Balance Your Diet

Regardless of your weight, income level or present state of health, you may not be getting enough of the nutrition you need if the variety and quality of foods in your diet is poor.

A balanced diet rich in nutrients, however, will help you look and feel better inside and out.

Good Nutrition = Prevention
 
           

Exercise Regularly

Physical activity can be divided into two types: aerobic and anaerobic. Aerobic exercise involves large muscle movements over a sustained period of time and includes activities such as:

• Running
• Fast walking
• Aerobic exercise classes

When you make aerobic activity a part of your regular routine, your heart and cardiovascular system become much healthier.

 
 
           

Drink Lots of Water

Drinking plenty of water is an important part of maintaining a healthy weight and a nutritious diet. Water plays an essential role in helping your body process nutrients, maintain normal circulation and keep the proper balance of fluids.

Replace What You Lose
After each 30-minute workout, drink two 8-ounce glasses of water to replenish your fluids. If you find you become thirsty while working out, consider using a sports bottle to help you stay hydrated while you exercise.