Healthy 4Life Assessment

Gender

Male

Female

Height (in cm)

Under 150 cm

Between 150 cm and 180 cm

Over 180 cm

Weight (in kg)

Under 45.0 kg

Between 45.0 and 90.0 kg

Between 90.0 and 135.0 kg

Over 135.0 kg

Do you smoke?

Yes

No

How much water do you drink each day?

1 glass (250 ml) or less

2 to 4 glasses (up to 1000 ml)

5 to 7 glasses (up to 1750 ml)

8 or more glasses (over 2000 ml)

How many servings do you eat of these food groups every day?

Fruits
(1 serving = 1 small apple and orange or 10 grapes or 1 medium banana)

Dairy
(1 serving = 1 cup of milk or yogurt or 1.5 ounces of cheese)

Vegetables
(1 serving = 3/4 cup (100 g) of cooked leafy vegetables or non-leafy vegetables, 100 g of raw non-leafy vegetables, or 150 g of raw leafy vegetables)

Nadhir

Healthy 4Life Assessment

Gender

Height (in cm)

Weight (in kg)

Do you smoke?

How much water do you drink each day?

How many servings do you eat of these food groups every day?

Fruits
(1 serving = 1 small apple and orange or 10 grapes or 1 medium banana)

Dairy
(1 serving = 1 cup of milk or yogurt or 1.5 ounces of cheese)

Vegetables
(1 serving = 3/4 cup (100 g) of cooked leafy vegetables or non-leafy vegetables, 100 g of raw non-leafy vegetables, or 150 g of raw leafy vegetables)

Whole Grains
(1 serving = 1/2 bowl of brown rice, wholegrain noodles or 2 slices of wholemeal bread)

Sugars
(1 serving = 1 cookie, 1 doughnut, or 1 piece of cake, etc.)

How many times a week do you eat the following:

Red meat

Fish

How often do you eat the same meal?
For example: salads, hamburgers, tacos, broccoli and beef, chicken noodle soup

How often do you have a bowel movement?

How much time do you spend sitting each day?

How many times per week do you spend at least 30 minutes doing the following types of activity?

Light Activity
(Minimal exertion, can talk easily or even sing)

Moderate Activity
(Heavier breathing, can talk with some effort, little to moderate sweating)

Intense Activity
(Labored breathing, difficult to talk, heavy sweating)

Please rate your current level of stress:

How many nights a week do you sleep for five hours or less?

Please rate your energy level:

Please rate the strength of your immune system:

What areas of your health would you like to support? (pick up to 3)

Healthy 4Life Assessment

Gender

Age

Height (in cm)

Weight (in kg)

Do you smoke?

How much water do you drink each day?

How many servings do you eat of these food groups every day?

Fruits (1 serving = 1 small apple and orange or 10 grapes or 1 medium banana)

Dairy (1 serving = 1 cup of milk or yogurt or 1.5 ounces of cheese)

Vegetables (1 serving = 3/4 cup (100 g) of cooked leafy vegetables or non-leafy vegetables, 100 g of raw non-leafy vegetables, or 150 g of raw leafy vegetables)

Whole Grains (1 serving = 1/2 bowl of brown rice, wholegrain noodles or 2 slices of wholemeal bread)

Sugars (1 serving = 1 cookie, 1 doughnut, or 1 piece of cake, etc.)

How many times a week do you eat the following:

Red meat

Fish

How often do you eat the same meal?For example: salads, hamburgers, tacos, broccoli and beef, chicken noodle soup

How often do you have a bowel movement?

How much time do you spend sitting each day?

How many times per week do you spend at least 30 minutes doing the following types of activity?

Light Activity(Minimal exertion, can talk easily or even sing)

Moderate Activity(Heavier breathing, can talk with some effort, little to moderate sweating)

Intense Activity(Labored breathing, difficult to talk, heavy sweating)

Please rate your current level of stress:

How many nights a week do you sleep for five hours or less?

Please rate your energy level:

Please rate the strength of your immune system:

What areas of your health would you like to support? (pick up to 3)

Fruits
(1 serving = 1 small apple and orange or 10 grapes or 1 medium banana)

Dairy
(1 serving = 1 cup of milk or yogurt or 1.5 ounces of cheese)

Vegetables
(1 serving = 3/4 cup (100 g) of cooked leafy vegetables or non-leafy vegetables, 100 g of raw non-leafy vegetables, or 150 g of raw leafy vegetables)

Whole Grains
(1 serving = 1/2 bowl of brown rice, wholegrain noodles or 2 slices of wholemeal bread)

Sugars
(1 serving = 1 cookie, 1 doughnut, or 1 piece of cake, etc.)

How often do you eat the same meal?
For example: salads, hamburgers, tacos, broccoli and beef, chicken noodle soup

Light Activity
(Minimal exertion, can talk easily or even sing)

Moderate Activity
(Heavier breathing, can talk with some effort, little to moderate sweating)

Intense Activity
(Labored breathing, difficult to talk, heavy sweating)