Level 1 Habit Assessment Form

Date / Time *

Date

Time

Name *

First

Last

Email *

Phone

Habits and Behaviours

Please indicate your actions for each question

I make time for healthy habits *

I exercise or do some movement *

I eat slowly *

I eat mindfully, with few distractions. I notice the taste and texture of my food *

I include some lean protein at most meals *

I include colorful fruits and/or vegetables at most meals *

I eat mostly slow digesting, high fibre, nutrient dense, complex carbohydrates, such as fruits, starchy vegetables, whole grains, beans and legumes *

I eat mostly healthy fats *

I eat mostly whole, minimally processed foods *

I plan most of meals or have a organised delivery of a wholesome meal service *

I make time to destress, relax and have fun *

I do purposeful recovery *

I practice good sleep hygiene and aim to get plenty of high quality sleep *

I can manage my stress and emotions without relying on food and eating *

I drink alcohol sparingly, or don’t drink at all *

I have at least one positive, supportive social connection *

I smoke *

Yes = 1 point
No = 10 points

Please List Your Total Score Below

Please add up and insert your score *

Your score 135 and above Crushing it! You might be ready for coaching at Level 2, if you want. 111-135 Doing well! Some coaching areas for improvement, but you can still feel pretty good about your Level 1 skills. 85-110 You might be doing well with some fundamental habits, but you’re probably struggling with others, think about more consistent coaching strategies for support. Less than 85 Coaching may significantly help?

Level 1 Habit Assessment Form

Habits and Behaviours

Please List Your Total Score Below

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