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Your Health Investment Questionnaire

For the highest degree of accuracy, please read each question carefully
rating yourself on a scale of (1) to (5). Give yourself a (5) if you are doing
very well in that question area. Give yourself a (1) if you're having difficulty
or are paying no attention in that question area.  

Once we have the answers you will receive a written report containing
recommendations for self improvement in three key healthy lifestyle areas:
Physical Activity, Nutrition/Supplementation and Stress Reduction.

Don't forget to click the SUBMIT button when you are finished.

Please check only ONE box per question.

Take your time and good luck!

First Name:
 *
Last Name:
 *
Email Address:
 *
Zip Code
 *
Nutrition
1. I eat more often with health in mind versus mood/wants.
1
2
3
4
5
2. I drink eight to ten classes of water daily.
1
2
3
4
5
3. I eat fiber-rich foods.
1
2
3
4
5
4. I drink less than seven alcoholic drinks each week.
1
2
3
4
5
5. I pay attention to portion sizes.
1
2
3
4
5
6. I drink less than one cup of coffee daily.
1
2
3
4
5
7. I eat few if any fried foods.
1
2
3
4
5
8. I eat a nutritious breakfast each morning.
1
2
3
4
5
9. I eat less than one dessert each day.
1
2
3
4
5
 
Self-Care
1. I've had a physical exam in the last three years.
1
2
3
4
5
2. I see a chiropractor acupuncturist or massage therapist.
1
2
3
4
5
3. I have purchased the necessary equipment to remain active.
1
2
3
4
5
4. I take vitamins and herbs to increase my health.
1
2
3
4
5
5. I get at least eight hours of restful sleep each night.
1
2
3
4
5
6. I turn off work/worries in a conscious way.
1
2
3
4
5
Personal Growth
1. I enjoy time alone.
1
2
3
4
5
2. I have an optimistic attitude and feel hopeful about my future.
1
2
3
4
5
3. I spend 10-30 minutes each day in quiet time/prayer.
1
2
3
4
5
4. I read books and listen to tapes that enhance my well being.
1
2
3
4
5
5. I make regular time for myself.
1
2
3
4
5
6. I am aware of my abilities and gifts.
1
2
3
4
5
7. I set healthy boundaries for myself with those around me.
1
2
3
4
5
8. I am learning to be more authentic with family and friends.
1
2
3
4
5
Physical Fitness
1. I park farther away to get more walking done.
1
2
3
4
5
2. I take the stairs instead of the elevator.
1
2
3
4
5
3. I spend 30 minutes every other day walking.
1
2
3
4
5
4. I take part in aerobic/yoga/dance classes regularly.
1
2
3
4
5
5. I lift weights for 30 minutes three times per week.
1
2
3
4
5
6. I do an aerobic activity three times each week.
1
2
3
4
5
7. I make sure to do full body stretching after exercise.
1
2
3
4
5
Stress Release
1. I do regular breathing exercises to calm my mind.
1
2
3
4
5
2. I take regular stress breaks from my desk or computer.
1
2
3
4
5
3. I take a 5 to10 minute walk to relax and clear my mind.
1
2
3
4
5
4. I participate in stretching/yoga/relaxation classes regularly.
1
2
3
4
5
5. I take part in regular fun activities or hobbies.
1
2
3
4
5
6. I am comfortable sitting and just doing nothing.
1
2
3
4
5
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Your Very Best Healthy Lifestyle Option

Sequoia Health & Fitness, Inc.
483A Carlisle Drive
Herndon, VA 20170-4819
703-464-5171

Email: Info@SequoiaHealth.com