Project Me lifestyle Inventory Client DetailsName* First Last Address* Street Address Address Line 2 Suburb State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* ExpectationsWhat do you expect to get out of our fortnightly 1:1 coaching sessions?Tell me something about yourself that you think I should know to coach you better?Briefly share your overall health and lifestyle goals. Where would you like to you see yourself in…1 Year / 5 Years / 10 YearsWhat would you like me as your coach to do if you find yourself falling behind your tasks or your own expectations?Complete this sentence (in detail) “I would be ecstatic if after this Program”….How to Hold Me AccountableOne of the most challenging aspects of coaching is knowing what to do when the person I’m working with is not completing the work we’ve agreed upon. How would you like to be held accountable?If you are not prepared for a scheduled meeting (first time), would you like me to:-Immediately request to rescheduleSpend the meeting discussing why you were unprepared and how to better manage your time.If you do not complete the work required to move forward toward your goals (first time), would you like me to:-Help you explore potential roadblocks and solutions.Revise our plan to include smaller sub-goals.EnergyIn a typical work-day, my energy is high, I am vigorous, and I am able to perform at my best.-OftenSometimesNeverRarelyWhen not working, my energy is high, I am vigorous, and I am able to perform at my best.-OftenSometimesNeverRarelyENERGY BOOSTERS I experience the following energy boosters in my life: Healthy sleep Regular exercise Healthy eating habits Stress mgt, relaxation, or fun activities Maintaining healthy weight Maintaining good physical health Healthy mindset Healthy work relationships Healthy family and personal relationships Healthy finances Job satisfaction List any other energy drains:ENERGY DRAINS I experience the following energy drains in my life: Poor or insufficient sleep Too little exercise Unhealthy eating habits Stress Weight management issues Physical health issues Pessimism or emotional issues Work relationship issues Family or relationship issues Financial issues Job Issues List any other energy boosters:Readiness for Change: On a scale of 1 to 10 (1 = Not, 10 = Very)How important is it that you make changes or improvements in your energy level at this time?012345678910How confident are you that you can make changes or improvements in your energy level at this time?012345678910SLEEP AND STRESSI get 7-8 hours of sleep at night.-OftenSometimesNeverRarelyMinor problems throw me for a loop.-OftenSometimesNeverRarelyI find it difficult to get along with people I used to enjoy.-OftenSometimesNeverRarelyNothing seems to give me pleasure anymore.-OftenSometimesNeverRarelyI am unable to stop thinking about my problems.-OftenSometimesNeverRarelyI feel frustrated, impatient, or angry much of the time.-OftenSometimesNeverRarelyI experience feelings of tension and anxiety.-OftenSometimesNeverRarelyI am coping well with my current stress load.-YesNoI have suffered a personal loss or misfortune in the past year. (For example: a job loss, disability, divorce, separation, or the death of someone close to you). If more than one loss or misfortune, indicate number:-YesNoI have friends and/or family with whom I can share problems and get help if needed.-YesNoI feel calm and peaceful.-OftenSometimesNeverRarelyI have a lot of energy.-OftenSometimesNeverRarelyI am a happy person.-OftenSometimesNeverRarelyI take the time to relax and have fun daily.-OftenSometimesNeverRarelyI feel downhearted or blue.-OftenSometimesNeverRarelyI feel worthless, inadequate, or unimportant.-OftenSometimesNeverRarelyReadiness for Change: On a scale of 1 to 10 (1 = Not, 10 = Very)How important is it that you make changes or improvements in your sleep and stress level at this time?012345678910How confident are you that you can make changes or improvements in your sleep and stress levels at this time?012345678910Life BalanceI maintain a comfortable balance between Work, Family, Friends and Self-OftenSometimesNeverRarelyThe area that I would most like to have more time for is:-WorkFamilyFriendsSelfReadiness for Change: On a scale of 1 to 10 (1 = Not, 10 = Very)How ready are you to make changes or improvements in your life balance at this time?012345678910How important is it that you make changes or improvements in your life balance at this time?012345678910How confident are you that you can make changes or improvements in your life balance at this time?012345678910WeightCurrent Weight (kgs) Weight 1 Year Ago (kgs) Weight 2 Years Ago (kgs) Weight 5 Years Ago (kgs) Weight 10 Years Ago (kgs) Waist To Hip Ratio (if known) I have utilised the following weight-management program(s) in the last 10 yearsReadiness for Change: On a scale of 1 to 10 (1 = Not, 10 = Very)How important is it that you make changes or improvements in your weight at this time?012345678910How confident are you that you can make changes or improvements in your weight at this time?012345678910ExerciseHow Many Days / Week Do You Perform The Following:Aerobic exercise – At least 20 minutes of vigorous intensity activity (fitness walking, cycling, jogging, swimming, aerobic dance, active sports) (3 or more days desirable) OR at least 30 minutes of moderate intensity activity (5 or more days desirable).01234567Strength exercises – At least 10 minutes of strength-building exercises (such as squats, push-ups, or use strength-training equipment) (2-3 days desirable)01234567Flexibility or stretching exercise – At least 5 minutes to improve flexibility of your back, neck, hips, shoulders, and legs (3 days desirable)01234567I currently have the following limitations on physical activity, if any (e.g., injuries, illness, medical conditions):I previously had the following limitations on physical activity, if any, over the last 5 years:Readiness for Change: On a scale of 1 to 10 (1 = Not, 10 = Very)How important is it that you make changes or improvements in your level of exercise at this time?012345678910How confident are you that you can make changes or improvements in your level of exercise at this time?012345678910NutritionI eat a full breakfast each day.-OftenSometimesNeverRarelyI eat “junk” snack foods between meals (e.g. chips, pastries, candy, ice cream, cookies).-OftenSometimesNeverRarelyI eat high fat food (such as hamburgers, hot dogs, cream, cheese, whole milk, eggs, butter, cake, pastry, ice cream, chocolate, fried foods, and many fast foods)-OftenSometimesNeverRarelyI eat low fat food (such as lean meats, skinless poultry, fish, skim milk, low fat dairy products, fruit desserts, vegetables, pasta, legumes (peas and beans).-OftenSometimesNeverRarelyI eat refined grain (such as white bread, rolls, regular pancakes and waffles, white rice, typical breakfast cereals, typical baked goods)-OftenSometimesNeverRarelyI eat whole grain (such as whole grain breads, brown rice, oatmeal, whole grain or high fiber cereals)-OftenSometimesNeverRarelyI eat 5 servings of fruits and vegetables daily.-OftenSometimesNeverRarelyI drink eight 8 glasses of water daily. (8 desirable)-OftenSometimesNeverRarelyI drink non-diet soft drinks daily.-OftenSometimesNeverRarelyI drink (how many) alcoholic drinks per week day I drink (how many) alcoholic drinks per weekend day Readiness for Change: On a scale of 1 to 10 (1 = Not, 10 = Very)How important is it that you make changes or improvements in your nutrition at this time?012345678910How confident are you that you can make changes or improvements in your nutrition at this time?012345678910HealthIn general, my overall health is excellent.-TrueFalseI have a primary care doctor whom I see regularly.-YesNoThe approximate date of my last physical exam: BLOOD PRESSURE: Have you ever been told you have high blood pressure? If so when and what was the reading?I am currently pregnant.-YesNoI had mammogram within the last 12 months.-YesNoI practice monthly breast self-exams for lumps-YesNoI have reached menopause (i.e. 12 months or more without menstruating)-YesNoI use drugs or medicines (include prescription and non prescription) that treat depression, affect my mood, help me relax, or help me sleep.-OftenSometimesNeverRarelyI have had bodily pain during the past month.-OftenSometimesNeverRarelyIf so, describe:During the past month, I have had difficulty doing work, or other regular activities, as a result of my physical health.-OftenSometimesNeverRarelyI smoke.-OftenSometimesNeverRarelyI have missed (how many days) from work due to illness or injury during the last 6 months. My doctor has informed me that I currently have the following health problems:Asthma or lung disorderN/ANot Under ControlOn MedicationBowel polyps or inflammatory bowel diseaseN/ANot Under ControlOn MedicationCancer, other than non-melanoma skin cancerN/ANot Under ControlOn MedicationChronic bronchitis or emphysema (COPD)N/ANot Under ControlOn MedicationCoronary heart disease, congestive heart failure, angina, heart attack, or heart surgeryN/ANot Under ControlOn MedicationDepression (mental illness)N/ANot Under ControlOn MedicationDiabetes (high blood sugar)N/ANot Under ControlOn MedicationHigh blood pressure (140/90 or higher)N/ANot Under ControlOn MedicationHigh blood cholesterol (200 or higher)N/ANot Under ControlOn MedicationSciatica or chronic back problem (musculoskeletal)N/ANot Under ControlOn MedicationStroke or restricted blood flow to head or legsN/ANot Under ControlOn MedicationArthritisN/ANot Under ControlOn MedicationI have had the following within the last month: Chest pain or discomfort, frequent palpitations or fluttering in the heart-YesNoUnusual shortness of breath-YesNoUnexplained dizziness or fainting-YesNoTrouble sleeping-YesNoTemporary sensation of numbness or tingling, paralysis, vision problem, or light-headedness-YesNoFrequent urination and unusual thirst-YesNoFrequent back pain-YesNoReadiness for Change: On a scale of 1 to 10 (1 = Not, 10 = Very)How important is it that you make changes or improvements in your health at this time?012345678910How confident are you that you can make changes or improvements in your health at this time?012345678910Signature
