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Physical Activity, Nutrition & Lifestyle
Nutritional Screening
How many meals do you typically eat each day?
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How many servings of fruits do you consume daily?
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How many servings of vegetables do you consume daily?
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How often do you eat snacks between meals?
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How often do you eat more than you intended (overeating)?
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How often do you eat less than you need (undereating)?
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How often do you skip meals?
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Do you find that your eating habits change significantly during social events?
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Do you eat in response to emotions (e.g., stress, sadness, boredom)?
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How often do you eat fast food or takeout meals?
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How often do you eat mindfully (paying attention to the experience of eating)?
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Do you have any dietary restrictions or preferences?
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Nutritional Knowledge and Satisfaction
On a scale of 1 to 10, how would you rate your current level of nutritional knowledge?
(1 = No knowledge, 10 = Very knowledgeable)
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Score:
How satisfied are you with your current eating habits?
(1 = Not satisfied, 10 = Very satisfied)
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Score:
Which areas of your diet do you feel need improvement? (Check all that apply)
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Which areas of your diet do you feel need improvement? (Check all that apply)
Increase fruit and vegetable intake
Reduce overeating
Improve meal regularity
Reduce emotional or social event-driven eating
Other (please specify):
Physical Activity Habits
On average, how many days per week do you engage in intentional physical
activity (walking, exercise, sports, etc.)?
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What types of physical activity do you typically perform? (Check all that apply)
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What types of physical activity do you typically perform? (Check all that apply)
Walking
Running or jogging
Strength training (weights, bodyweight exercises)
Cycling
Swimming
Yoga, Pilates, or stretching
Recreational sports (e.g., tennis, basketball)
Other (please specify):
How intense is your typical physical activity?
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Do you feel your current level of activity meets your health and wellness goals?
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Hydration Habits
On average, how many cups (8 oz servings) of water do you drink per day?
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Do you routinely drink other beverages that contribute to hydration (e.g., herbal
tea, electrolyte drinks)?
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Life Satisfaction
Please reflect on your overall sense of fulfillment and meaning in life.
Overall, how satisfied are you with your life as a whole right now?
(1 = Extremely dissatisfied, 10 = Extremely satisfied)
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Score:
In which areas of your life do you feel most satisfied? (Check all that apply)
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In which areas of your life do you feel most satisfied? (Check all that apply)
Health
Relationships (family, partner, friendships)
Career / Work
Personal Growth
Recreation / Hobbies
Financial Security
Spirituality / Connection
Other (please specify):
In which areas would you like to see improvement? (Check all that apply)
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In which areas would you like to see improvement? (Check all that apply)
Health
Relationships
Career / Work
Personal Growth
Recreation / Hobbies
Financial Security
Spirituality / Connection
Other (please specify):
I feel that my life has a clear sense of purpose.
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I feel connected to something larger than myself (e.g., family, community, personal
mission, spirituality).
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When facing challenges, I am able to find meaning or growth opportunities in the
experience.
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Do you currently use tobacco?
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If currently, how many packs per day?
If used to, when did you quit?
Do you use recreational drugs?
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If yes, how often and which ones?
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Alcohol Use
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Submit