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Lifestyle Review Questionnaire
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Lifestyle Review Questionnaire
Lifestyle Review Questionnaire
BGDLuke
2019-01-14T11:46:28+00:00
Your name *
First name
*
Last name
*
Date
*
DD slash MM slash YYYY
Our role is to guide and coach you. We do not compare or judge, so please be honest.
01. What is your primary goal for joining Viavi:be?
*
02. Considering everything else competing for your time right now, how important is it for you to take the action required to achieve this personal goal?
*
1 (Not at all) - 10 (Very much)
1
2
3
4
5
6
7
8
9
10
03. How confident are you that you will be able to achieve this?
*
1 (Not at all) - 10 (Very much)
1
2
3
4
5
6
7
8
9
10
04. What would initial success look like for you at a follow up review in 3 months time?
*
05. How keen are you to receive information and support on the following areas of your lifestyle?
1 (No help wanted) - 10 (As much support as possible)
Nutrition
*
1
2
3
4
5
6
7
8
9
10
Stress
*
1
2
3
4
5
6
7
8
9
10
Sleep
*
1
2
3
4
5
6
7
8
9
10
Being active
*
1
2
3
4
5
6
7
8
9
10
Managing ageing
*
1
2
3
4
5
6
7
8
9
10
06. If possible, name three current behaviours you are keen to improve over the coming three months. This could be to stop doing something you perceive as negative for your health and wellbeing, or equally, this may be an intent to start or stick with positive behaviours.
*
07. Please summarise in the following areas how you have felt in the last 6 weeks
1 (strongly disagree) - 10 (strongly agree)
Fitness and movement
I feel fit
*
1
2
3
4
5
6
7
8
9
10
I feel strong
*
1
2
3
4
5
6
7
8
9
10
I feel agile
*
1
2
3
4
5
6
7
8
9
10
I feel flexible
*
1
2
3
4
5
6
7
8
9
10
I move pain free
*
1
2
3
4
5
6
7
8
9
10
Clinical nutrition
I feel nourished
*
1
2
3
4
5
6
7
8
9
10
I feel my diet is well balanced
*
1
2
3
4
5
6
7
8
9
10
My hunger feels well controlled
*
1
2
3
4
5
6
7
8
9
10
I am able to control my weight through eating
*
1
2
3
4
5
