Are You At Risk?
Could you be at risk for developing heart disease or Type-2 diabetes? This questionnaire can help you determine whether or not you may be at risk.
Please fill out the following information and receive a FREE assessment.
First Name:
Last Name:
E-mail Address:
Age:
Gender:
Male
Female
Height:
(in feet and inches)
feet
inches
Weight:
(in pounds)
*Waist Circumference:
(in inches)
*Obtaining your waist circumference.
For the most accurate results, someone else should measure your waist circumference. Stand erect with your feet together, abdomen relaxed and your arms at your side. Place a measuring tape around the waist which is the narrowest part of the torso. Be sure the tape is completely straight in the horizontal plane.
1)
Currently how active are you? (How many minutes per day, on average, do you devote to exercise?)
0 Inactive
10 Minutes
20 Minutes
30 Minutes
40 Minutes
50 Minutes
60+ Minutes
2)
How active are you willing and able to be? (Be sure you can maintain this commitment!)
0 Inactive
10 Minutes
20 Minutes
30 Minutes
40 Minutes
50 Minutes
60+ Minutes
3)
Do you belong to a gym or use a community work out facility?
Yes
No
No, but I prefer to work out at home or on my own.
4)
How would you most closely describe your current eating habits?
I eat a very healthy, balanced diet.
Usually I eat a very healthy, balanced diet, and only sometimes I do not.
Usually I do not eat a healthy, balanced diet.
My eating habits are terrible.
5)
How would you describe your dieting history?
I have tried many diets over the years and never achieve success.
I have tried many diets over the years and I have achieved temporary success.
I have tried only a few diets and have achieved some degree of success.
I have dieted before and been successful.
I have never been on a diet before.
6)
Do you keep a journal or log book of your exercise and eating habits?
Yes
No
