BALANCEWELL NUTRITION & LIFESTYLE ASSESSMENT

Your Roadmap to a Healthier, More Active Life

Dear Visitor,
This assessment is designed to help us gain clarity on your current habits. There are no right or wrong answers—just honest ones. Your responses will help us tailor a plan that fits your life, not the other way around.
Your responses are completely confidential. By answering these questions honestly, you’ll receive valuable insights and access to exclusive resources that can guide you toward a more balanced and healthier life.

Newsletter

GOALS & MOTIVATION
GOALS & MOTIVATION
NUTRITION & EATING HABITS
NUTRITION & EATING HABITS
NUTRITION & EATING HABITS
NUTRITION & EATING HABITS
NUTRITION & EATING HABITS
NUTRITION & EATING HABITS
NUTRITION & EATING HABITS
NUTRITION & EATING HABITS
NUTRITION & EATING HABITS
PHYSICAL ACTIVITY & FITNESS
PHYSICAL ACTIVITY & FITNESS
PHYSICAL ACTIVITY & FITNESS
PHYSICAL ACTIVITY & FITNESS
PHYSICAL ACTIVITY & FITNESS
PHYSICAL ACTIVITY & FITNESS
SLEEP & REST
SLEEP & REST
STRESS
STRESS
WORK-LIFE BALANCE
SOCIAL SUPPORT & RELATIONSHIPS
MOTIVATION & READINESS FOR CHANGE
MOTIVATION & READINESS FOR CHANGE
MOTIVATION & READINESS FOR CHANGE
MOTIVATION & READINESS FOR CHANGE
YOUR MESSAGE

What is your primary wellness objective?

Lose weight

Gain weight

Improve overall health

Eat healthier

Increase daily energy & focus

Build sustainable healthy habits

Feel better in my body

Other

On a scale of 1-10, how important is this goal to you right now?

How would you currently describe your overall eating habits?

Mostly nutritious and balanced

Somewhat balanced with occasional indulgences

Inconsistent – I eat well some days and poorly on others

Poor – mostly convenience and processed foods

I'm not really thinking about what I eat

How many servings of fruits and vegetables do you consume on an average day?

5 or more servings

3-4 servings

1-2 servings

Almost none

How aware are you of portion sizes and do you practice portion control?

Very aware – I consistently practice portion control

Somewhat aware – I try to control portions most of the time

Neutral – I think about it occasionally

Not very aware – I eat until I feel full

Not aware at all – I don't think about portion sizes

What is your daily water intake?

8+ glasses (2+ liters) per day

5-7 glasses per day

2-4 glasses per day

Less than 2 glasses per day

I rarely drink water – mostly other beverages

How often do you consume sugary drinks, energy drinks, or beverages with added sugars?

Never or rarely

A few times per month

A few times per week

Daily

Multiple times daily

How much of your diet consists of processed foods with added sugars or unhealthy fats?

Very little – I prioritize whole foods

Some – I'm mindful but not strict

A moderate amount

Quite a lot – it's convenient

Most of my diet – I don't think much about ingredients

Do you have knowledge about macronutrient balance (proteins, carbohydrates, healthy fats)?

Yes, very knowledgeable – I balance these intentionally

Somewhat knowledgeable – I understand the basics

Limited knowledge – I've heard about it

Minimal knowledge – I'm not sure what this means

No knowledge at all – I don't think about this

How would you describe your typical breakfast?

Balanced and nutritious (Protein + Healthy Fats + Carbs)

Mostly carbs (Cereal, toast, pastry)

I usually skip breakfast and eat later in the day

Whatever is quick and available

Other

How confident are you that you know how to eat in a way that supports long-term weight loss and health?

Very confident

Confident

Not confident

Not confident at all

How many days per week do you engage in intentional physical activity (30+ minutes)

5-7 days per week

3-4 days per week

1-2 days per week

Less than 1 day per week

I don't exercise regularly

What is your primary reason for not exercising more (if applicable)?

I exercise enough – no barrier

Lack of time

Lack of motivation or energy

Physical discomfort or health concerns

Don't know where to start or lack of knowledge

Other

How would you rate your daily energy levels?

Excellent – I can do daily activities without strain

Good – I feel fit for most daily activities

Fair – I get tired doing moderate activity

Poor – I feel fatigued easily

Very poor – I struggle with basic movement

Do you incorporate strength training or muscle-building activities into your routine?

Yes, 3+ times per week

Yes, 1-2 times per week

Occasionally – less than once per week

Rarely

Never

How much time do you spend in sedentary activities (sitting, screens) on an average day?

Less than 3 hours

3-6 hours

6-9 hours

9-12 hours

12+ hours

Do you feel you would be more consistent with exercise if you had structure, guidance, or accountability?

Yes

Maybe

How many hours of sleep do you typically get per night?

7-9 hours (optimal)

6-7 hours

5-6 hours

4-5 hours

Less than 4 hours

How would you rate the quality of your sleep?

Excellent – I sleep soundly and wake refreshed

Good – I usually sleep well

Fair – I have some sleep issues

Poor – I often struggle with sleep

Very poor – I rarely get good sleep

How would you describe your current stress level?

Low – I feel generally calm and in control

Moderate – I have stress but manage it well

Elevated – I feel stressed several times per week

High – I'm frequently stressed

Very high – I feel overwhelmed most days

How do you typically cope with stress?

Healthy ways (exercise, meditation, talking, hobbies)

Mostly healthy with occasional unhealthy coping

Mixed – both healthy and unhealthy methods

Mostly unhealthy (food, alcohol, avoidance, etc.)

I don't have effective coping strategies

Other

Do you have time for activities you enjoy outside of work and obligations?

Yes, plenty of time for hobbies and leisure

Some time – I can enjoy activities occasionally

Limited time – rarely can pursue interests

Very limited – almost no time for myself

No time – my life is all work/obligations

Do you feel you have someone who would support you in making lifestyle changes?

Absolutely – strong accountability partner available

Yes – I have people who would help

Maybe – I'm not sure who would support me

Unlikely – I'd be doing this alone

No – I don't have that kind of support

On a scale of 1-10, how much do you feel you need to make changes to your lifestyle for your health?

How confident are you that you could make meaningful lifestyle changes if you decided to?

Very confident – I can do this

Fairly confident – I think I can succeed

Somewhat confident – it would be challenging

Not very confident – I doubt I could stick with it

Not confident at all – I don't believe I can change

Do you feel you would be more consistent if you had a structured plan and a supportive community/mentor?

Yes, absolutely

Maybe

No, I prefer to do it alone

How ready are you to begin making positive lifestyle changes?

Very ready – I'm prepared to start immediately

Ready – I plan to start soon

Somewhat ready – I'm considering it

Not ready yet – I need more time

Not ready – I'm not thinking about this yet

Your message or question (optional)

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