The Health Protocol New Starter Questionnaire

Your Details
Name*
Age*
Location*
Current weight*
Height*
Occupation
What is your occupation?*
How many hours a week on average do you work?*
Does your job require a long period of sitting?*
- Yes
- No
A lot would be considered more than 40% of your day.
On a scale of 1-10 how stressful do you find your job?*
1-2 = My work is as calm as a monastery 3-5 = It has its moments but generally its pretty chilled 6-7 = At least a couple of times a month the pressure is on 8-9 = I frequently have sleepless nights and the pressure is always on 10 = Im frequently frazzled by the pressure and its affecting my life
How do you tend to deal with stressful periods in work/life?*
Physical Activity
In the last 12 months how often have you participated in some kind of exercise?*
- 3 to 4 times per week
- 1 to 2 times per week
- 1 to 2 times per month
- Not at all
Do you do a daily step count? If so, what tends to be your average daily step? If you don’t, if you were to guess, what would your daily step count be?*
On a scale of 1-10 How fit do you think you are?*
1-2 = I get out of breath walking up 10 stairs 3-4 = I could walk a mile but I'd be sweating 5-6 = I do a weekly 5k but thats about it 7-8 = I can run, lift and jump and do so regularly 9-10 = I could run a marathon or do a gruelling workout tomorrow
What physical activities do you enjoy doing regularly? How regularly??*
If you have attempted to lose weight in the past utilising a form of exercise, what form of exercise has worked for you?*
Nutrition
How often do you eat takeaways?*
- Weekly
- Once or twice a month
- Every couple of months
- Never
How many pieces of fruit and veg do you typically consume a day?*
Do you mostly make your meals from scratch?*
- Yes
- No
If you make most of your meals but use jarred sauces, this would still be considered cooking from scratch.
How much processed food do you eat a day?*
- 0
- 1-3
- 4-6
- 6+
Consider each piece as a portion, so a pack of crisps are a portion as is a bowl of ice cream for example.
Do you mostly bring your own lunch to work (pre-covid)*
- Yes
- No
Consider 4 of the 5 days in a working week as 'mostly'.
What do you find the hardest meal to stay on point? Why?*
"on point" = fits with the health intentions you set out?
Do you tend to eat and drink differently at weekends compared to during the week? If yes, How?*
What is your biggest food vice?*
Do you eat meat?*
- Yes
- No
Do you snack in between meals?*
- Yes
- No
Would you say you are a binge eater? Describe an example of this?*
Do you drink Alcohol? How many units a week*
- I never drink
- I only drink every couple of months
- Less than 3 units a week
- 4-8 units a week
- 9-14 units a week
- 15+ units a week
1 unit = shot of spirits, 2.1 units = standard size glass wine, 3 units = pint beer, 9 units = bottle wine.
A year from now when you are fitter, healthier and leaner, what will you miss most about how you eat & drink in the past?*
Mood
What hobbies do you have (either physical or non physical)?*
How often do you experience stress?*
- Daily
- Couple of times a week
- Couple of times a month
- Hardly ever
What do you do to relax?*
Typically what times do you tend to go to bed and wake up? If it’s very sporadic please say so with a small description of what you mean.*
How would you describe the quality of your sleep?*
- I could sleep through a hurricane
- I wake up regularly but fall asleep again
- I wake up at a certain point and can't get back to sleep again
- I sleep fine. Not too light, not too deep
When you are stressed do you try to feel better with food?*
If yes, what foods do you tend to eat?
if yes, How do you feel after?
Past Attempts
Have you tried diets in the past? If so, what was most successful? What didn’t work at all?*
What tends to be the main stumbling blocks that stopped you being as successful at losing weight and/or being healthier in the past?*
When you’ve encountered a setback in the past what methods/resources have you adopted to rectify the situation? What did you find most successful? Note: If you haven't found any successful methods just say the ones you've tried.*
Health Aspirations
Why now? Why do you want to lose weight and become healthier now?*
Having successfully lost weight and adopted more of a health based mindset, what do you see as being different? What will you be doing you are not doing now? How will you feel about yourself and your capabilities? 12 months from now? 18 months from now? 3 years from now?*
Overall Health
Have You Experienced Any Heart Problems*
- Yes
- No
If 'yes' please elaborate further in 'other' box
If yes, Please provide further details
Do you have diabetes?*
- Yes
- No
If yes, please specify which one
- Type 1
- Type 2
Do you have any history of cancer?*
- Yes
- No
If yes, please provide more info
Do you suffer from epilepsy?*
- Yes
- No
Do You Ever Experience Pains In Your Chest or Heart During Physical Activity?*
- Yes
- No
Do You Get Out Of Breathe Easily?*
- Yes
- No
for example, walking up or down stairs, lifting things, running for something etc?
Do You Have Joint or Bone Problems That Could Be Aggravated By Exercise?*
- Yes
- No
If yes, could you provide more information?
Has Your Doctor Ever prescribed Medication For Blood Pressure Or Heart Conditions?*
- Yes
- No
Are You Currently Pregnant?*
- Yes
- No
Have You Given Birth Within The Last 2 Years?
Have You Had Any Surgery In The Last 10 Years?*
- Yes
- No
If yes, please provide some details
Do You Have High Blood Pressure*
- Yes
- No
Do You Have High Cholesterol?*
- Yes
- No
- Havent checked

Your Details

Occupation

Physical Activity

Nutrition

Mood

Past Attempts

Health Aspirations

Overall Health