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HEALTHY LIVING EVALUATION
LWA HEALTHY LIVING COMMUNITY
HEALTHY LIVING CONCIERGE
LWA 21-DAY CHALLENGE
JUMP START: 14-DAYS WITH LWA
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THE LIVING WITH ASHLEY LIFESTYLE QUESTIONNAIRE
Living with Ashley Lifestyle Questionnaire
NAME
EMAIL
CURRENT WEIGHT
GOAL WEIGHT
AGE
18-24
25-29
30-34
35-39
40-44
45+
Reason(s) for seeking out a nutritionist + healthy living coach
Have you worked with a healthy living professional (nutritionist, trainer, coach) in any capacity?
If you answered YES to the above: What type + when? What did you achieve? What didn’t you like about previous experiences?
Have you dieted in the past? What diets have you tried + what were the results?
Have you had any dramatic weight gains or losses in the last year? If so, explain below:
Check the boxes of the healthy living practices you have the most trouble with
Meal Planning and prep
Time to grocery shop and cook
Working out regularly
Knowing how to exercise for your specific goals
Stress management
Consistent and quality sleep
What to eat specifically for your goals
How to cook
Overall motivation and accountability
Write your food and drink intake below for the last 3 days
Grocery shopping habits: How often do you go to the grocery store? Do you go with a list? Where do you shop?
List 5 of your top restaurants or food delivery places you order from + write out the menu items you order
Are you willing to commit to meal prep and planning practices?
Yes
No
YOUR DAY: how many meals and snacks do you eat in a day?
Check the boxes of all common feelings you have before +/or after you eat a meal
BEFORE: Overly hungry, famished
BEFORE: Forcing yourself to eat (aka: not hungry)
AFTER: Bloated +/or gassy
AFTER: Overly full (want to unbutton my pants full)
AFTER: Still hungry, unsatisfied (after a decent-sized meal)
BEFORE or AFTER: Headaches
BEFORE or AFTER: Tired, sluggish
Now, think through these answers and try to place what you ate at mealtime if you felt “sick” (nauseous, bloated, gassy…)
Check the box that describes your average day's energy level.
Mostly high energy
Mostly low energy
Up and down throughout the day
If you answered up and down throughout the day above, explain the times of day you are at highest energy and lowest.
Check the boxes of sleeping patterns you have on the average night.
I have trouble falling asleep
I have trouble staying asleep
I get up a lot throughout the night
I wake up still tired
I crave a nap most days
My average night's sleep is less than 6 hours
Describe your weekly workout routine including your workout type, frequency, and duration.
What do you think you would benefit from most when it comes to guidance regarding fitness?
Write down any wellness practices you do regularly. (I.E. light therapy, infrared sauna, meditation or digital detox, detox/salt baths, journaling, massage, et al.)
What are your biggest stressors in your daily life? These can be listed categorically (financial, love life, parenting, work, et al.) or specific/situationally.
On a scale from 1-10, how stressed are you from day-to-day?
When (+ where) do you feel most at peace and balanced?
Who acts as your biggest support system on a daily basis? Will they be on board for healthy living changes?
Check the boxes of any and all of the help you think would help you live healthier.
Receiving pre-made menus with recipes and meal prep tips for the week
Interactive, online group motivational coaching
Food journaling for a professional to review
Help evaluating and redesigning your fitness regimen
Cooking lessons, in any way or specific to meal prep
Weekly one-on-one coaching sessions
24-7 access to a nutritionist, trainer, + chef coach
Eating out and ordering in guidance
What is your ideal budget when it comes to health + wellness services per month?
$0-25
$26-99
$100-149
$150-199
$199+
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