Survey Your Starting Point

Complete the survey below by tracking it in your journal or using the “Print on Demand”. This survey looks at the “big picture” – your overall goals, current habits, strengths, weaknesses, support system, and other factors that influence behavior. Each question has a purpose. Complete all sections. This is one of many opportunities in this guide for self-discovery and reflection.

Be honest with yourself. If you are working with a coach, answers to these questions may help your coach tailor the program to your needs. If you are using HealthyLife® Weigh on your own, the prompts throughout the guide will help you “coach” yourself!

My Current Habits Survey

Today’s Date:

My Height:

My Current Weight:

Have you been told to lose weight for health reasons?

Which medical conditions that apply to you:

*   Diabetes

*   Prediabetes

*   High blood pressure

*   High cholesterol

*   Heart disease

*   Heart attack

*   Stroke

*   Cancer

*   Chronic back pain

*   Arthritis

*   Asthma

*   Sleep apnea

REMEMBER:The guidelines in HealthyLife® Weigh do not take the place of medical advice. If you are managing a chronic health condition or taking medication, it is important to let your doctor know of any changes you are making to your diet and exercise habits.

Indicate how strongly you agree or disagree with the following statements. If how you feel varies, select how you feel on most days.

*  My current weight puts me at higher risk for health problems.

*  I know the benefits of a well-balanced diet.

*  I know the benefits of making regular physical exercise a part of my daily lifestyle.

*  I am confident in my ability to reach my physical activity goals.

*  I am confident in my ability to improve my eating habits.

*  I eat for emotional reasons (stress, boredom, joy, etc.) several times a week.

*  Making changes to my health is a priority for me.

*  Choices I make daily affect my health risks in the future.

*  I am confident in my ability to improve how I manage stress.

*  I have control over the direction my life is taking.

*  It is not wise to plan too far ahead because many things turn out to be a matter of luck anyway.

*  When I make plans or set goals, I am almost certain that I can make them work and achieve my goals.

Identify the habits you have already adopted, those you are in the process of changing, and those you do not intend to change right now.

*  Exercise five times per week for 30 minutes at a moderate intensity.*

*  Take the stairs or park a little farther away.

*  Eat five servings of fruits & vegetables daily.**

*  Choose foods high in fiber (such as whole grains, oatmeal, beans, & lentils).

*  Limit added sugars to fewer than 25 grams (6 tsp.) per day.

*  Keep healthy food options in my kitchen and limit unhealthy options.

*  Choose restaurants that offer healthy menu options.

*  Moderate intensity exercise includes brisk walking, active gardening/yard work, or any  activity that raises your heart rate.

**A serving of fruits and vegetables equals one small piece of fruit (about the size of a baseball), ½ cup cooked vegetables, or 1 cup of raw vegetables.

Which cooking skills you feel confident doing:

*  Cooking on the stove

*  Cooking in the microwave

*  Cooking in the oven

*  Chopping vegetables

*  Boiling water

*  Opening a can

*  Using the toaster

*  Using a blender

*  Using measuring utensils

*  Following a recipe

*  Using a food scale

*  Using a toaster oven

*  Cooking on the grill

*  Freezing leftovers

*  Modifying a recipe

What cooking skills do you want to learn or improve? This guide gives some tips to prepare foods. For more recipes, tips, and demonstrations, consider taking a cooking class, watch videos online, or watch cooking shows on TV.

What are your favorite ways to prepare food? In this guide, you will learn healthy ways to prepare foods. You don’t have to completely change how you like to prepare food. Often, a small step can make a big difference-and be just as convenient!