Self-Assessment Part 1

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Your Relationship with Food, Your Body, & Yourself

Email *

The purpose of this assessment is to help me customize your coaching. The first step to transformation is awareness. Only once we’re aware of the thoughts, beliefs, and behaviors that are keeping you stuck can we create the most effective plan to change them. When practiced consistently over time, the transformational tools I'll be providing will allow you to make powerful shifts in how you eat, move, and think, so that you can build a healthy body and meaningful life you love!

Full Name *

Birthdate *

YYYY

Height *

Approximate Weight *

Which of the following are true (or mostly true) for you when it comes to food? *

I have been on and off diets much of my adult life

I weigh myself more than once a week

I look at a meal and immediately guess how many calories or grams of protein, carbs, and fat it contains

My weight often yo-yos more than 7 pounds any given year

I seek out meal plans to follow or else I’d feel lost as to what I should eat

I feel “safer” when I track all my calories and macros

I feel guilty and shameful when my will power is not strong enough to stick to my meal plan

I don’t eat unhealthy or “fattening” foods when I’m around others

I exercise to burn off calories I feel guilty about consuming

I often wait until I’m starving to eat, and then I end up binging

I often say, “I already messed up by eating a few _____ so I may as well finish them all and start fresh tomorrow”

I often avoid social situations because I don’t want to be tempted by foods I’m trying to stay away from

I often eat while I’m working, watching tv, or driving

When I eat depends on when I think I should, not necessarily when I feel hungry

I use food to comfort myself when I’m feeling down or stressed out

I use diet pills, metabolism boosting pills, or other weight-loss supplements

I often rush through meals, not paying close attention to how well I chew, or the flavors or texture of the food

Required

Which of the following are true (or mostly true) for you when it comes to your body? *

I often compare my body to others and end up feeling depressed or jealous

I “feel fat” most of the time

I often compliment other people’s bodies

I often miss, or have to fight myself to get to social events because of how I look

I “hate” certain parts of my body

I try to figure out how to change the way my body looks daily

I worry what people will think if they see me eating anything unhealthy

I avoid being in photos as much as possible

I feel frustrated that my body won’t change the way I want it to

I look in the mirror and see all my flaws immediately

I think about how happy I would be if only I liked how my body looked

I find myself pinching the skin on parts of my body to test how much fat there is

My feelings about my appearance get in the way of me accepting myself or enjoying life

Required

Which of the following are true (or mostly true) for you when it comes to your emotional health? *

I often manage stress in unhealthy ways (e.g. over-eating, drinking alcohol, isolating self)

I often get so overwhelmed by negative emotion that I feel like I spiral out of control

I do not assertively stand up for myself when someone takes advantage of me or treats me disrespectfully

I get defensive, sad, and/or angry when criticized

I tend to put everyone else’s needs before my own

I have trouble creating balance in my life

I have trouble “letting go” of anger and resentment

I tend to disconnect from others and hide when I’m feeling down

I have trouble assertively voicing my needs

I have trouble saying, “no” to people, and when I do say no, I often feel guilty

It’s difficult for me to make a long list of all my strengths

I consider myself a “perfectionist”

I consider myself an anxious person overall

I have trouble making deep connections with other people and/or creating intimacy

I feel shameful about things that have happened in my life in the past

I stress about not having enough money

I stress about not having enough time

Required

The top 5 things I value in my life / in this world are... *

I am motivated to make positive changes in the way I eat, move, and think because... *

My greatest strengths are... *

The biggest hurdles keeping me from reaching my health and fitness goals are... *

The vision I have for myself and my life following the Coaching Program is... *

A copy of your responses will be emailed to the address you provided.

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