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Lifestyle Review Questionnaire
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Lifestyle Review Questionnaire
Lifestyle Review Questionnaire
Viavi:be
2019-01-14T11:46:28+00:00
Your name *
First name
*
Last name
*
Date
*
Date Format: 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
6
7
8
9
10
I am happy with how I eat
*
1
2
3
4
5
6
7
8
9
10
Energy recovery
I feel free from stress
*
1
2
3
4
5
6
7
8
9
10
I feel calm
*
1
2
3
4
5
6
7
8
9
10
I feel focused
*
1
2
3
4
5
6
7
8
9
10
My body feels rested
*
1
2
3
4
5
6
7
8
9
10
I have sufficient energy
*
1
2
3
4
5
6
7
8
9
10
Managing ageing
I feel well
*
1
2
3
4
5
6
7
8
9
10
I am free from aches and pains
*
1
2
3
4
5
6
7
8
9
10
I am happy with how my skin looks
*
1
2
3
4
5
6
7
8
9
10
I feel younger than my age
*
1
2
3
4
5
6
7
8
9
10
I feel I have a strong immune system
*
1
2
3
4
5
6
7
8
9
10
08. Toxicity
How many times do you travel by aeroplane each year?
*
Less than 2
2-5
6-10
More than 10
Do you regularly apply sun protection on sunny days? Not only on holidays
*
Never
Sometimes
Often
Always
Do you have any amalgam fillings?
*
Yes
No
Do you live within 100m of a major road?
*
Yes
No
Do you currently smoke or have you been a regular smoker in the past 5 years?
*
Yes
No
Do you dye your hair regularly with non-natural based colours?
*
Yes
No
What percentage of your food is organic?
*
Less than 50%
More than 50%
09. General health
If you suffer from any of the following, please tick if applicable:
Hypertension
Diabetes
High cholesterol
Heart disease
Arrhythmia
Stroke
Migraine or regular headaches
Memory decline
Stress disorder
Fatigue disorder
Low immune system
Hormone imbalance
Hypothyroidism
Hyperthyroidism
Coeliac disease
Inflammatory bowel disease (IBS)
Autoimmune disorder
Anxiety
Depression
Skin rashes, eczema, psoriasis
Other (please state)
Other:
*
