how many days per week to you get physical activity that increases your heart rate? 

How would you describe the intensity of the activity most weeks?  

I get ____ minutes each time I complete an activity that increases my heartrate.  This number may vary, please use the average or typical minutes.  If you like to take a brisk walk 4 days per week; is that for 30 minutes, 60 minutes each time you walk? 

On the average weekday how many hours are you active during the day?

On the average weekend or non-working days; how many hours are you typically active? 

How many hours do you typically sit during the weekdays?

List lifestyle activities you enjoy and how often you try to include them in your routine.  (ex: hiking, 2 days monthly, bike ride 1 hour weekly, swim 1 hour weekly, etc.)

How often do you include resistance activities in your weekly routine? 

Describe the type of resistance activities and how long you typically do that activity.  (ex: lift weights, full body 2 days per week for 60 minutes, cross fit, 2 days per week for 30 minutes, etc.)

Please share any information about your physical activity we may have left out. 

Most days, how many times do you eat?

What best describes the quality of your food choices? 

Do you follow any of the following diet plans? (can be for health, weight loss or personal reasons)

Provide any additional information about your diet, eating habits that we did not address. 

Describe how you approach desserts.  What type of dessert, how often and if you are within your personal goal for desserts or would like to improve?  Any additional information regarding desserts and snacking you would like to share. 

Describe any body changes you noticed you feel are related to mid-life.  They can include, but not limited to: increased waist circumference, hot flashes, exhaustion, mood swings, anxiety, weight gain, etc.

Your Height

What is your current weight and goal weight?

What is your waist circumference?  (Use a tape measure to wrap around your waist at the top of your hipbone, usually at the level of your belly button).

Have you previously had bariatric surgery? 

Are you currently taking a weight loss medication? 

Have you been diagnosed with any medical condition (food allergy, type 2 diabetes, celiac, etc.)  you have been told to follow a specific diet? 

PHYSICAL SELF-CARE (NUTRITION, HYDRATION, ACTIVITY, REST AND RELAXATION):

Eat regularly (e.g. Breakfast, Lunch, Dinner)

Eat Healthy Foods

Exercise (planned)

Get preventative medical care

Get medical care when needed

Take time off when needed

Get massages

Be active: dance, swim, walk, run, play sports, sing, or do some other physical activity you find fun. 

Get enough sleep (according to your needs). 

Wear clothes you like. 

Take vacations. 

Take day trips or mini vacations. 

Make time to be away from telephones. 

PSYCHOLOGICAL SELF-CARE:

Make time for reflection. 

Have your own personal psychotherapy.

Write in a journal. 

Read literature that is unrelated to work. 

Do something which you are not an expert or in charge. 

Decrease stress in your life. 

Let others know different aspects of you. 

Notice your inner experiences-listen to your thoughts, judgements, beliefs, attitudes, and feelings. 

Engage your intelligence in a new area, e.g. go to an art museum, history exhibit, sports event, auction theater performance, etc. 

Practice receiving from others. 

Be curious. 

Say "no" to extra responsibilities when needed. 

Other Psychological Self-Care. 

EMOTIONAL SELF-CARE: 

Spend time with others whose company you enjoy.

Stay connected to important people in your life.

Give yourself affirmations, praise yourself.

Love yourself.

Re-read favorite books, re-review favorite movies/series.

Identify comforting activities, objects, people, relationships, places, and seek them out. 

Allow yourself to cry. 

Find things that make you laugh. 

Express your outrage in social action, letters, and donations, marches, protests. 

Play with children. 

Other Emotional Self-Care needs:

SPIRITUAL SELF-CARE:

Make time for reflection. 

Spend time with nature. 

Find a spiritual connection or community. 

Cherish your optimism and hope. 

Be aware of nonmaterial aspects of life. 

Try at times not to be in charge or the expert. 

Be open to not knowing. 

Identify what is meaningful to you and notice its place in your life.

Meditate

Pray

Have experiences of awe.

Contribute to causes in which you believe. 

Read inspirational literature.

Other spiritual self-care:

WORKPLACE OR PROFESSIONAL SELF-CARE:

Take a break during the workday (e.g. lunch). 

Take time to chat with co-workers.

Make quiet time to complete tasks. 

Identify projects or tasks that are exciting and rewarding. 

Set limits with your clients and colleagues. 

Balance your caseload so that no one day or part of a day is "too much".

Arrange your workspace so it is comfortable and comforting. 

Get regular consultation. 

Negotiate for your needs (benefits, pay, time off). 

Have a peer support group. 

Strive for a balance within your work-life and workday. 

Strive for balance among work, family, relationships, play and rest. 

Other professional self-care practices.

ACTIVITY: Our physical, mental, and emotional health are impacted by the amount and kind of movement we do. Moving the body can take many forms such as dancing, walking, gardening, yoga, and exercise. Physical activity has a strong relationship with hunger control. 

Where you are: Rate yourself on a scale of 1 (low) to 5 (high) 1 2 3 4 5  

Where would you like to be? 1 2 3 4 5  

RECHARGE: Our bodies and minds must rest and recharge in order to optimize our health. Getting a good night’s rest, as well as recharging our mental and physical energy throughout the day, impact hunger response in the body. Taking short breaks or doing something you enjoy or feels good for moments throughout the day are examples of ways to refresh.  

Where you are: Rate your

self on a scale of 1 (low) to 5 (high) 1 2 3 4 5  

Where would you like to be? 1 2 3 4 5  

NUTRITION: What we eat and drink can have a huge effect on how we experience life, both physically and mentally. Energy, mood, weight, how long we live, and overall health are all impacted by what and how we choose to eat and drink.  Quality of food and/or getting sufficient food are both implications in hunger control.

Where you are: Rate yourself on a scale of 1 (low) to 5 (high) 1 2 3 4 5  

Where would you like to be? 1 2 3 4 5  

PERSONAL DEVEOPMENT: Our health is impacted by how we choose to spend our time. Aligning our work and personal activities with what really matters to us, or what brings us joy, can have a big effect on our health and outlook on life.

Where you are: Rate yourself on a scale of 1 (low) to 5 (high) 1 2 3 4 5  

Where would you like to be? 1 2 3 4 5  

RELATIONSHIPS: Our relationships, including those with pets, are as important to our health and well-being as any other factor. Spending more time in relationships that ‘fuel’ us and less in relationships that ‘drain’ us is one potential option. Isolation and lack of personal connection is related to overeating. 

Where you are: Rate yourself on a scale of 1 (low) to 5 (high) 1 2 3 4 5  

Where would you like to be? 1 2 3 4 5 

SPIRITUALITY: Connecting with something greater than ourselves may provide a sense of meaning and purpose, peace, or comfort. Connecting and aligning spiritually is very individual and may take the form of religious affiliation, connection to nature, or engaging in things like music or art.

Where you are: Rate yourself on a scale of 1 (low) to 5 (high) 1 2 3 4 5  

Where would you like to be? 1 2 3 4 5  

ENVIRONMENT, both at work and where we live, indoors and out, can affect our health and outlook on life. Changes within our control such as organizing, decluttering, or adding a plant or artwork can improve mood and health.

Where you are: Rate yourself on a scale of 1 (low) to 5 (high) 1 2 3 4 5  

Where would you like to be? 1 2 3 4 5  

THOUGHTS/MINDSET: Our thoughts are powerful and can affect our physical, mental, and emotional health. Changing our mindset can aid in healing and coping. Thoughts have a significant impact on eating habits, stress and resilience. 

Where you are: Rate yourself on a scale of 1 (low) to 5 (high) 1 2 3 4 5 

 Where would you like to be? 1 2 3 4 5