Lifestyle Assessment Form Exercise

Do I currently do any form of exercise? ________________________________

If so, what exercise(s)? ____________________________________________

How often? ______________________________________________________

What kinds do I enjoy most? ________________________________________

Do I reward myself (other than with food) for exercising? _________________

Do I use exercise to enhance my social life (for example, exercise with friends)?

Diet

What is my current eating schedule (3 meals a day, snacks, beverages, etc.)?

What foods do I eat most often? _____________________________________

Do I overeat? ____________________________________________________

About how many calories do I consume in a day? _______________________

Am I overweight? _________________________________________________

How many times per week do I eat out? _______________________________

Figure 3.1 Lifestyle assessment form.

Daily Log