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+ Submit If you are human, leave this field blank. Tags:FitnessNutritionQuestionnaireThe Living with Ashley Lifestyle QuestionnaireWellness
