Lifestyle Profile

Name:

E-mail:     

A. Caffeine Usage/Rest

1. How many caffeinated beverages (including coffee) do you drink per day?
   

   None
   1-2
   3-5
   6+

2. How many hours of sleep do
   you get at night?
   

B. Nutrition

1. Which of the following food groups do you get at least one serving of per day (check all that apply):
   
   meat, fish, poultry, beans, eggs or nuts
   milk or dairy products
   bread or grains
   fruits and vegetables
   
   
2. Do you eat breakfast?
   

   Yes
   No

3. Do you eat between meals?
   

   Yes
   No

4. Do you eat after 7:00 pm?
   

   Yes
   No

5. Present Weight:
   One Year Ago:
   At age 25:
   
   
6. Do you consider yourself overweight?
   

   Yes
   No

7. Are you presently dieting?
   

   Yes
   No

C. Tobacco Use

If you currently smoke, how many years have you been smoking?

1. Never smoked (skip to question #6)
   Used to smoke
   Currently smoke

2. If you currently smoke, how many years have you been smoking?
   
   
3. How much do you smoke per day?
   
   
4. Have you attempted to quit?
   

   Yes
   No

5. If you have quit smoking, how long ago did you quit?
   
   
   
6. Do you live with someone who smokes?
   

   Yes
   No

7. Do you use smokeless tobacco?
   

   Yes
   No

D. Alcohol Use

On average, how many alcoholic beverages do you drink per week?

E. Stress Management

1. What is your current level of stress in your life?
   

   Low
   Moderate
   High

2. List any way you respond to stress in terms of physical symptoms, behaviors.
   
   
   
   
3. List any stress management techniques that you use.
   

F. Exercise

1. Describe your current fitness level:
   

   Very Good
   Good
   Fair
   Poor

2. Do you exercise on a regular basis?
   

   Yes
   No

3. Do you consider your overall lifestyle (work, school, home activities) to be:
   

   Sedentary
   Moderatately Active
   Active
   Extremely Active

4. List any activities in which you regularly participate (include frequency and duration):
   
   
   
   
5. List any injuries or medical problems that may affect your physical activity.
   
   
   
   
6. Please list any goals that you would like to
   attain through your exercise program.