Quality of Life Review

Complete the form below by answering each of the questions.

When ranking on a scale of 1-10 (1 – very dissatisfied, 5 – ok, could be better, 10 – very satisfied)

Once you have completed all of your responses, add your total score and hit the submit button.

Quality of Life Review

Name*
First Last
Email*
Rate Your Level of Satisfaction with your physical health on a scale of 1-10*
If less than 10, what would you like to change?
If less than 10, what would you like to change?
Rate Your Level of Happiness with your current weight on a scale of 1-10*
If less than 10, what would you like to change?
If less than 10, what would you like to change?
Rate Your Level of Satisfaction with your daily/weekly exercise patterns on a scale of 1-10
If less than 10, what would you like to change?
If less than 10, what would you like to change?
Check any of the items below that apply regarding your daily nutritional patterns:*
- My nutritional intake is primarily real, whole foods
- My nutritional intake includes a lot of fast food
- My nutritional intake includes eating out more than 5 times per week
- I eat 3 good meals per day
- I eat 3 good meals per day with 2-3 small snacks
- I skip breakfast
- I skip lunch
- I eat too much at night
- I drink alcohol occasionally
- I drink alcohol daily
- I struggle with sugar cravings
- I struggle with cravings for salty foods
What if anything would you like to shift, start or stop in your nutritional patterns?
Do you have any chronic pain or ongoing illness? If yes, please describe
How often to you schedule and take (honor) ME Time?*
How often do you schedule long weekends, vacations and time to relax and rejuvenate?*
Do you have a daily practice for getting centered, breathing, being intentional about your day?*
Anything else that would be helpful for Lori to know?
Name
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