Healthy Lifestyle Profile Assessment
Dr. Fred Bisci, Ph.D.
Your Healthy Journey
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A.   INVESTIGATE
Age:
 Gender:
 Male
 Female
1.   Name:
Email:
City and State:
Phone:
Alternate Phone:
2.  Check Yes if You Eat, Drink, or Use:
Non-Herbal Teas
Tobacco and/or Cigarette Products
Sweetened Fruit Drinks / Pasteurized Juices
Alcohol
Roasted and Salted Nuts
Candy
Pork Products
Carbonated Beverages / Soda Pop
Medications
Coffee
Processed Foods
Artificial Sweeteners
Refined (White) Flour Products
Fluoridated / Chlorinated Water
Distilled Water
At Fast Food Restaurants Regularly
Canned Vegetables / Soups and Grains
Fried Foods
Daily Fresh Vegetables
Luncheon Meats
Boxed Cereals / Grains
Margarine
Salt / Pepper / Hot Spices
Refined Sugars
Chew Tobacco
Dairy / Milk Products
TV Dinners
 Vitamins and Minerals
3.  Check Yes if You:
Exercise More Than 3 Times Weekly
Are Exposed to Cigarette Smoke
Exercise Less Than 3 Times Weekly
Drink During Your Meal
Go Back and Forth on Diets
Exercise and Your Muscles are Sore
Are Consistent with your Eating Choices
Have Weight Gain
Are Exposed to Chemicals at Work or Home
Easily Fatigued
Are Under Excessive Stress
Apply Salt Before Tasting
Have Difficulty Gaining Weight
Eat Between Meals
Have Indigestion
Eat Meat More Than 3-4 Times Weekly
Worry and Feel Insecure
Eat Meat Less Than 3-4 Times Weekly
Have Gas After Your Meal or Throughout the Day
Lead a Stress Free Life
Have Any Cravings
B.   EDUCATE
Do You Want to Learn More About:
Finding my Ideal Body Weight
Slowing Down the Aging Process
Seeing Things More Clearly
Being Stronger Than You are Today
How Your Body Heals You
A Long Healthy Life
A Better Night's Sleep
Handling Stress and a Peaceful Mind
Having More Stamina and Endurance
A Doable Menu for You
Feeling Better Than You Feel Now
Learning How to Properly Combine Foods
Eating Healthier
Eating a Meal That Will Energize Me and Not Exhaust Me
More Energy in General
Increasing My Physical Activity During
Recreational and Family Events
Be Stronger with Greater Coordination
and Performance During Sport Activities
C.   INTEGRATE
List Five Goals / Results You Want to Achieve:
1.

2.

3.

4.

5.
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The Healthy Journey Lifestyle Conference