Your Health Journey Forward Starts Today!

Free Assessment - Coach Lisa

Please complete this survey independently. If you are participating with a partner or colleague from your workplace, be sure to mention them in your responses. Your answers are private and unique to you. Upon completion, you’ll receive personalized feedback to support your wellness and health improvement journey.

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* 1. Your name

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* 2. Please indicate how you would like to receive your personalized results and coach feedback.

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* 3. I am making a health change alongside my partner, friend, teammate, or another companion.

Yes

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* 4. If you’re embarking on this health change with someone else, please share their name so we can create your team baseline. Make sure your partner completes this survey as well—you’re going to love this!

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* 5. How would you describe your primary role in your community? (Select all that apply)

Full or Part-time at Home Parent

Full Time at Workplace Outside the Home

Self Employed (within or outside the home)

Volunteer

Student

Other (please share)

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* 6. At this moment, how would you describe your personal purpose? (It’s okay if this feels challenging to define or is evolving—reflecting on it can be valuable, as it influences your lifestyle and any changes you make.)

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* 7. To what extent do you agree or disagree with the following statements? Be honest—your responses are incredibly valuable in guiding you toward a meaningful, successful path to a healthier and more fulfilling life.

	Strongly disagree	Some what disagree	Neither agree or disagree	Some what agree	Strongly agree
I am comfortable making lifestyle changes gradually.	I am comfortable making lifestyle changes gradually. Strongly disagree	I am comfortable making lifestyle changes gradually. Some what disagree	I am comfortable making lifestyle changes gradually. Neither agree or disagree	I am comfortable making lifestyle changes gradually. Some what agree	I am comfortable making lifestyle changes gradually. Strongly agree
I tend to have an all-or-nothing mindset when it comes to nutrition or exercise.	I tend to have an all-or-nothing mindset when it comes to nutrition or exercise. Strongly disagree	I tend to have an all-or-nothing mindset when it comes to nutrition or exercise. Some what disagree	I tend to have an all-or-nothing mindset when it comes to nutrition or exercise. Neither agree or disagree	I tend to have an all-or-nothing mindset when it comes to nutrition or exercise. Some what agree	I tend to have an all-or-nothing mindset when it comes to nutrition or exercise. Strongly agree
I usually react objectively and calmly if I do not reach my exercise or nutrition goals and try to learn from my mistakes.	I usually react objectively and calmly if I do not reach my exercise or nutrition goals and try to learn from my mistakes. Strongly disagree	I usually react objectively and calmly if I do not reach my exercise or nutrition goals and try to learn from my mistakes. Some what disagree	I usually react objectively and calmly if I do not reach my exercise or nutrition goals and try to learn from my mistakes. Neither agree or disagree	I usually react objectively and calmly if I do not reach my exercise or nutrition goals and try to learn from my mistakes. Some what agree	I usually react objectively and calmly if I do not reach my exercise or nutrition goals and try to learn from my mistakes. Strongly agree
I use food as a reward; to deal with stress; or to relieve boredom.	I use food as a reward; to deal with stress; or to relieve boredom. Strongly disagree	I use food as a reward; to deal with stress; or to relieve boredom. Some what disagree	I use food as a reward; to deal with stress; or to relieve boredom. Neither agree or disagree	I use food as a reward; to deal with stress; or to relieve boredom. Some what agree	I use food as a reward; to deal with stress; or to relieve boredom. Strongly agree
I have opportunities for fun in my life.	I have opportunities for fun in my life. Strongly disagree	I have opportunities for fun in my life. Some what disagree	I have opportunities for fun in my life. Neither agree or disagree	I have opportunities for fun in my life. Some what agree	I have opportunities for fun in my life. Strongly agree
I spend my time in a way that is in line with my values.	I spend my time in a way that is in line with my values. Strongly disagree	I spend my time in a way that is in line with my values. Some what disagree	I spend my time in a way that is in line with my values. Neither agree or disagree	I spend my time in a way that is in line with my values. Some what agree	I spend my time in a way that is in line with my values. Strongly agree
I practice effective stress management.	I practice effective stress management. Strongly disagree	I practice effective stress management. Some what disagree	I practice effective stress management. Neither agree or disagree	I practice effective stress management. Some what agree	I practice effective stress management. Strongly agree
I am a worthy person, and deserve to take good care of myself through a healthy diet and physical activity.	I am a worthy person, and deserve to take good care of myself through a healthy diet and physical activity. Strongly disagree	I am a worthy person, and deserve to take good care of myself through a healthy diet and physical activity. Some what disagree	I am a worthy person, and deserve to take good care of myself through a healthy diet and physical activity. Neither agree or disagree	I am a worthy person, and deserve to take good care of myself through a healthy diet and physical activity. Some what agree	I am a worthy person, and deserve to take good care of myself through a healthy diet and physical activity. Strongly agree
I try to engage in some sort of physical activity on most days of the week.	I try to engage in some sort of physical activity on most days of the week. Strongly disagree	I try to engage in some sort of physical activity on most days of the week. Some what disagree	I try to engage in some sort of physical activity on most days of the week. Neither agree or disagree	I try to engage in some sort of physical activity on most days of the week. Some what agree	I try to engage in some sort of physical activity on most days of the week. Strongly agree
My home and work environments support a healthy lifestyle.	My home and work environments support a healthy lifestyle. Strongly disagree	My home and work environments support a healthy lifestyle. Some what disagree	My home and work environments support a healthy lifestyle. Neither agree or disagree	My home and work environments support a healthy lifestyle. Some what agree	My home and work environments support a healthy lifestyle. Strongly agree
I eat my meals and snacks mindfully.	I eat my meals and snacks mindfully. Strongly disagree	I eat my meals and snacks mindfully. Some what disagree	I eat my meals and snacks mindfully. Neither agree or disagree	I eat my meals and snacks mindfully. Some what agree	I eat my meals and snacks mindfully. Strongly agree
I monitor my eating and activity behaviors.	I monitor my eating and activity behaviors. Strongly disagree	I monitor my eating and activity behaviors. Some what disagree	I monitor my eating and activity behaviors. Neither agree or disagree	I monitor my eating and activity behaviors. Some what agree	I monitor my eating and activity behaviors. Strongly agree
I consider myself someone who actively promotes or advocates for healthy living.	I consider myself someone who actively promotes or advocates for healthy living. Strongly disagree	I consider myself someone who actively promotes or advocates for healthy living. Some what disagree	I consider myself someone who actively promotes or advocates for healthy living. Neither agree or disagree	I consider myself someone who actively promotes or advocates for healthy living. Some what agree	I consider myself someone who actively promotes or advocates for healthy living. Strongly agree

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* 8. Indicate how well you feel you are currently managing the following areas of your lifestyle on a regular basis.

	Not managing	Some days I do well	50-50	Doing well most of the time	Doing great! / Not an issue for me	N/A
Overall health	Overall health Not managing	Overall health Some days I do well	Overall health 50-50	Overall health Doing well most of the time	Overall health Doing great! / Not an issue for me	Overall health N/A
Self-esteem	Self-esteem Not managing	Self-esteem Some days I do well	Self-esteem 50-50	Self-esteem Doing well most of the time	Self-esteem Doing great! / Not an issue for me	Self-esteem N/A
Energy level	Energy level Not managing	Energy level Some days I do well	Energy level 50-50	Energy level Doing well most of the time	Energy level Doing great! / Not an issue for me	Energy level N/A
Stress management	Stress management Not managing	Stress management Some days I do well	Stress management 50-50	Stress management Doing well most of the time	Stress management Doing great! / Not an issue for me	Stress management N/A
Weight management	Weight management Not managing	Weight management Some days I do well	Weight management 50-50	Weight management Doing well most of the time	Weight management Doing great! / Not an issue for me	Weight management N/A
Mood management	Mood management Not managing	Mood management Some days I do well	Mood management 50-50	Mood management Doing well most of the time	Mood management Doing great! / Not an issue for me	Mood management N/A
Quality of sleep	Quality of sleep Not managing	Quality of sleep Some days I do well	Quality of sleep 50-50	Quality of sleep Doing well most of the time	Quality of sleep Doing great! / Not an issue for me	Quality of sleep N/A
Concentration	Concentration Not managing	Concentration Some days I do well	Concentration 50-50	Concentration Doing well most of the time	Concentration Doing great! / Not an issue for me	Concentration N/A
Physical fitness	Physical fitness Not managing	Physical fitness Some days I do well	Physical fitness 50-50	Physical fitness Doing well most of the time	Physical fitness Doing great! / Not an issue for me	Physical fitness N/A
Eating habits	Eating habits Not managing	Eating habits Some days I do well	Eating habits 50-50	Eating habits Doing well most of the time	Eating habits Doing great! / Not an issue for me	Eating habits N/A
Interpersonal relationships	Interpersonal relationships Not managing	Interpersonal relationships Some days I do well	Interpersonal relationships 50-50	Interpersonal relationships Doing well most of the time	Interpersonal relationships Doing great! / Not an issue for me	Interpersonal relationships N/A
Quality of life	Quality of life Not managing	Quality of life Some days I do well	Quality of life 50-50	Quality of life Doing well most of the time	Quality of life Doing great! / Not an issue for me	Quality of life N/A
Effectiveness at work	Effectiveness at work Not managing	Effectiveness at work Some days I do well	Effectiveness at work 50-50	Effectiveness at work Doing well most of the time	Effectiveness at work Doing great! / Not an issue for me	Effectiveness at work N/A
Appearance	Appearance Not managing	Appearance Some days I do well	Appearance 50-50	Appearance Doing well most of the time	Appearance Doing great! / Not an issue for me	Appearance N/A
Disease prevention	Disease prevention Not managing	Disease prevention Some days I do well	Disease prevention 50-50	Disease prevention Doing well most of the time	Disease prevention Doing great! / Not an issue for me	Disease prevention N/A
Coping with a chronic disease	Coping with a chronic disease Not managing	Coping with a chronic disease Some days I do well	Coping with a chronic disease 50-50	Coping with a chronic disease Doing well most of the time	Coping with a chronic disease Doing great! / Not an issue for me	Coping with a chronic disease N/A
Commitment to new health habits	Commitment to new health habits Not managing	Commitment to new health habits Some days I do well	Commitment to new health habits 50-50	Commitment to new health habits Doing well most of the time	Commitment to new health habits Doing great! / Not an issue for me	Commitment to new health habits N/A

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* 9. What healthy habits do you already practice? If you participate in specific activities or classes at a local health club, please list them.

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* 10. What additional lifestyle changes are you ready to make, if any?

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* 11. What lifestyle change are you most excited to make or improve? If you’re participating with a partner or teammate, which change are you most eager to work on together? (This is your chance to state your dream!)

Thank you for completing the survey!

With Lifestyle Coaching, you’re not just a participant—you’re the expert, fully in the driver’s seat of your own transformation. I’m excited to walk this journey with you as your coach, supporting and empowering you every step of the way.
Let’s do this!
Coach Lisa

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* 12. Date you completed this survey

Date / Time

Date