check

Comprehensive Food Freedom Assessment

Please complete this questionnaire before your Comprehensive Food Freedom Assessment appointment, dedicating approximately 30 minutes to provide thoughtful responses. Your honesty is essential to crafting a personalized coaching plan tailored to your sustainable weight loss goals that result in a sculpted body. The form explores your weekly nutrition habits, typical physical activity levels, self-care practices and priorities, and a self-assessment of eight key health areas to reflect your current wellness journey.

Click the button below to start.

Start

Question 2 of 98

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

A

0-2 Days

B

3-4 Days

C

4-7 Days

Question 3 of 98

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

A

A stroll, you can talk or even sign.

B

A moderate intensity; can talk would have a difficult time signing.

C

An intense activity: I struggle to talk.

Question 4 of 98

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? 

A

Less than 30 minutes

B

30-45 minutes

C

45-60 minutes

D

60+ minutes

Question 5 of 98

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

A

Less than 1 hour

B

1-2 hours

C

2-6 hours

D

Most of the day

E

Other

Question 6 of 98

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

A

Less than 1 hour

B

1 - 2 hours

C

2 - 6 hours

D

Most of the day

E

Other

Question 7 of 98

How many hours do you typically sit during the weekdays?

A

Less than 2 hours

B

2 - 6 hours

C

Most of the day

D

Other

Question 8 of 98

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.)

Question 9 of 98

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

A

None

B

1 - 2 days

C

3 - 6 days

D

Daily

Question 10 of 98

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.)

Question 11 of 98

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

Nutrition

Question 13 of 98

Most days, how many times do you eat?

A

1 meal, no snacks

B

1 meal with small snacks

C

2 meals, no snacks

D

2 meals with small snacks

E

3 meals, no snacks

F

3 meals with small snacks

G

I fast on a regular basis.

H

Often a chaotic meal schedule, often grabbing something quick instead of meals.

I

Often experience difficulty in stopping eating when full.

J

Other

Question 14 of 98

What best describes the quality of your food choices? 

A

I mostly eat healthy foods.

B

I mostly eat packaged meals (ex; boxed foods, canned foods, frozen meals).

C

Most meals are home cooked.

D

I eat out most meals.

Question 15 of 98

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

A

Vegan

B

Vegetarian

C

Low Carbohydrate

D

Low Fat

E

Low Calorie

F

Carnivore

G

Mediterranean Style

H

Other

Question 16 of 98

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

Question 17 of 98

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. 

Medical History

Provide a brief medical history to the best of your knowledge.  This information is used to assess and recommend a nutrition that best fits you as well as the most appropriate nutritional approach for weight loss.  

Question 19 of 98

Your Height

Question 20 of 98

What is your current weight and goal weight?

Question 21 of 98

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).

Question 22 of 98

Have you previously had bariatric surgery? 

A

Yes

B

No

C

Unsure

Question 23 of 98

Are you currently taking a weight loss medication? 

A

Yes, GLP-1

B

Yes, GIP

C

Yes, Contrave

D

Yes, Qsymia

E

Yes, Phentermine

F

Yes, other

G

Not currently, however, I previously tried a weight loss medication.

H

No

Question 24 of 98

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

Self-Care

This assessment tool provides an overview of effective strategies to maintain self-care related to overall health, wellness and reduce psychological hunger.  This assessment tool is to be used with the self-care inventory as it provides more details in each of the areas of self-care.  It is not necessary to strive for each area; however, this is to be used as a tool for you to identify what you may be lacking personally. 

Use this scale to rate the following areas in the terms of frequency: 5 = Frequently, 4= Occasionally, 3 = Rarely, 2 = Never, 1 = It never occurred to me.

Question 26 of 98

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

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

Question 27 of 98

Eat Healthy Foods

Question 28 of 98

Exercise (planned)

Question 29 of 98

Get preventative medical care

Question 30 of 98

Get medical care when needed

Question 31 of 98

Take time off when needed

Question 32 of 98

Get massages

Question 33 of 98

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

Question 34 of 98

Get enough sleep (according to your needs). 

Question 35 of 98

Wear clothes you like. 

Question 36 of 98

Take vacations. 

Question 37 of 98

Take day trips or mini vacations. 

Question 38 of 98

Make time to be away from telephones. 

Question 39 of 98

PSYCHOLOGICAL SELF-CARE:

Make time for reflection. 

Question 40 of 98

Have your own personal psychotherapy.

Question 41 of 98

Write in a journal. 

Question 42 of 98

Read literature that is unrelated to work. 

Question 43 of 98

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

Question 44 of 98

Decrease stress in your life. 

Question 45 of 98

Let others know different aspects of you. 

Question 46 of 98

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

Question 47 of 98

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

Question 48 of 98

Practice receiving from others. 

Question 49 of 98

Be curious. 

Question 50 of 98

Say "no" to extra responsibilities when needed. 

Question 51 of 98

Other Psychological Self-Care. 

Question 52 of 98

EMOTIONAL SELF-CARE: 

Spend time with others whose company you enjoy.

Question 53 of 98

Stay connected to important people in your life.

Question 54 of 98

Give yourself affirmations, praise yourself.

Question 55 of 98

Love yourself.

Question 56 of 98

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

Question 57 of 98

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

Question 58 of 98

Allow yourself to cry. 

Question 59 of 98

Find things that make you laugh. 

Question 60 of 98

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

Question 61 of 98

Play with children. 

Question 62 of 98

Other Emotional Self-Care needs:

Question 63 of 98

SPIRITUAL SELF-CARE:

Make time for reflection. 

Question 64 of 98

Spend time with nature. 

Question 65 of 98

Find a spiritual connection or community. 

Question 66 of 98

Cherish your optimism and hope. 

Question 67 of 98

Be aware of nonmaterial aspects of life. 

Question 68 of 98

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

Question 69 of 98

Be open to not knowing. 

Question 70 of 98

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

Question 71 of 98

Meditate

Question 72 of 98

Pray

Question 73 of 98

Have experiences of awe.

Question 74 of 98

Contribute to causes in which you believe. 

Question 75 of 98

Read inspirational literature.

Question 76 of 98

Other spiritual self-care:

Question 77 of 98

WORKPLACE OR PROFESSIONAL SELF-CARE:

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

Question 78 of 98

Take time to chat with co-workers.

Question 79 of 98

Make quiet time to complete tasks. 

Question 80 of 98

Identify projects or tasks that are exciting and rewarding. 

Question 81 of 98

Set limits with your clients and colleagues. 

Question 82 of 98

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

Question 83 of 98

Arrange your workspace so it is comfortable and comforting. 

Question 84 of 98

Get regular consultation. 

Question 85 of 98

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

Question 86 of 98

Have a peer support group. 

Question 87 of 98

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

Question 88 of 98

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

Question 89 of 98

Other professional self-care practices.

SELF-CARE INVENTORY RATING

There are 8 areas of self-care that relate to health.  Improving self-care and making sure your needs are met have a significant impact on overall health and control overeating.  We find that improving the areas below reduce overeating and can help maintain a healthier weight and overall well-being.  Many of the areas below are inter-related and can impact each other.  Small changes can lead to significant improvements in overall well-being and hunger control.   

Question 91 of 98

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  

Question 92 of 98

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  

Question 93 of 98

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  

Question 94 of 98

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  

Question 95 of 98

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 

Question 96 of 98

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  

Question 97 of 98

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  

Question 98 of 98

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  

Confirm and Submit