WEIGHTLOSS COACHING ASSESSMENT

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This assessment form's purpose is to collect relevant data on your current lifestyle

Email *

Mobile contact *

Gender? *

Male

Female

What is your primary goal *

Lose weight

Gain Muscle

Develop healthy habits

Required

How much weight are you looking to lose after a period of 3-6 months? *

Less than 5kgs

5-10kgs

10-15kgs

over 15kgs

Describe your typical day *

At the office all day

Daily long walks

Physical work

Mostly at home

Time since your ideal weight *

Less than 1 year

1-2 years

More than 3 years

Never

Select habits that are true for you *

I eat late at night

I don't get enough sleep

I can't give up on sweets

I love soft drinks

I cant exercise consistently for more than 2 weeks

Required

How physically active are you? *

Barely

I workout 1-2 times a week (Lightly active)

I workout 3-5 times a week (Moderately active)

I work out 5-7 times a week (Very active)

How many hours do you sleep? *

Less than 5 hours

5-6 hours

7-8 hours

More than 8 hours

Are you able to maintain your energy during the day *

My energy levels do not fluctuate

I drag before meals

I feel sleepy after lunch

Do you relate to this statement: I'm afraid I wont have time to do other things I love because I'll be so busy exercising and planning meals *

Yes

Mark the vegetables you would want included in your meal plan *

Brocolli

Mushrooms

Spinach and kale

Cucumbers and Carrots

Sweet potatoes

Cabbage

Local greens ( Managu, terere, sagaa)

Lettuce and Red cabbage

Required

Proteins *

Turkey

Fish(Salmon, Tilapia , Nile Perch)

Beef

Mutton

Chicken

Omena

None

Required

Fats *

Avocado

Natural Yorgurt

Peanut butter

Cheese

Nuts

Milk

Eggs

Required

Starch *

Brown Rice

Brown Chapati

Brown Ugali

How much time do you have for meal planning everyday *

Less than 30 mins

30-60 mins

No time at all

What exercise can you participate in regularly? *

Walking

Jogging

Zumba/ aerobics

Weight Lifting

I'm in no shape to actively work out

How much time do you have for exercise everyday *

Less than 30 mins

30-60 mins

Over 1 hour

Lastly, what can you identify as your biggest obstacle when it come to improving your health and achieving your desired goal weight? *

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