4Life Wellbeing Assessment

Gender

Male

Female

Weight (in kg)

Under 45 kg

Between 46 and 65 kg

Between 66 kgs and 75 kgs

Between 76 kgs and 85 kgs

Between 86 kgs and 135 kgs

Over 136 kgs

Height (in cm)

150 cm or under

Between 151 cm and 180 cm

Over 180 cm

Do you smoke?

Yes

No

How much water do you drink each day?

1 glass (25 ml) or less

2 to 4 glasses (up to 1 l)

5 to 7 glasses (up to 1,75 l)

8 or more glasses (over 2 l)

How many servings do you eat of these food groups every day?

Fruits (1 serving = 130 - 150 g)

Dairy (1 serving = 250 ml of milk, 125 g of yogurt or fresh cheese)

Vegetables (1 serving = 150 g uncooked)

Whole Grains (1 serving = 40 - 60 g of bread or 60 - 80 g of pasta or rice)

Sugars (1 serving = 1 cookie, 1 doughnut, or 1 piece of cake, etc.)

How many times a week do you eat the following:

Red meat

Fish

How often do you eat the same meal?
For example: salads, hamburgers, tacos, broccoli and beef, chicken noodle soup

How often do you have a bowel movement?

Once every 3 or more days

Once every 1-2 days

Once a day

2-3 times a day

More than 3 times a day

How much time do you spend sitting each day?

1-2 hours

3-4 hours

5-7 hours

8 or more hours

Kh TP

4Life Wellbeing Assessment

Gender

Weight (in kg)

Height (in cm)

Do you smoke?

How much water do you drink each day?

How many servings do you eat of these food groups every day?

Fruits (1 serving = 130 - 150 g)

Dairy (1 serving = 250 ml of milk, 125 g of yogurt or fresh cheese)

Vegetables (1 serving = 150 g uncooked)

Whole Grains (1 serving = 40 - 60 g of bread or 60 - 80 g of pasta or rice)

Sugars (1 serving = 1 cookie, 1 doughnut, or 1 piece of cake, etc.)

How many times a week do you eat the following:

Red meat

Fish

How often do you eat the same meal?
For example: salads, hamburgers, tacos, broccoli and beef, chicken noodle soup

How often do you have a bowel movement?

How much time do you spend sitting each day?

How many times per week do you spend at least 30 minutes doing the following types of activity?

Light Activity
(Minimal exertion, can talk easily or even sing)

Moderate Activity
(Heavier breathing, can talk with some effort, little to moderate sweating)

Intense Activity
(Labored breathing, difficult to talk, heavy sweating)

Please rate your current level of stress:

How many nights a week do you sleep for five hours or less?

Please rate your energy level:

Please rate the strength of your immune system:

What areas would you most like to support? (pick up to 3)

4Life Wellbeing Assessment

Gender

What is your age?

Weight (in kg)

Height (in cm)

Do you smoke?

How much water do you drink each day?

How many servings do you eat of these food groups every day?

Fruits (1 serving = 130 - 150 g)

Dairy (1 serving = 250 ml of milk, 125 g of yogurt or fresh cheese)

Vegetables (1 serving = 150 g uncooked)

Whole Grains (1 serving = 40 - 60 g of bread or 60 - 80 g of pasta or rice)

Sugars (1 serving = 1 cookie, 1 doughnut, or 1 piece of cake, etc.)

How many times a week do you eat the following:

Red meat

Fish

How often do you eat the same meal?For example: salads, hamburgers, tacos, broccoli and beef, chicken noodle soup

How often do you have a bowel movement?

How much time do you spend sitting each day?

How many times per week do you spend at least 30 minutes doing the following types of activity?

Light Activity(Minimal exertion, can talk easily or even sing)

Moderate Activity(Heavier breathing, can talk with some effort, little to moderate sweating)

Intense Activity(Labored breathing, difficult to talk, heavy sweating)

Please rate your current level of stress:

How many nights a week do you sleep for five hours or less?

Please rate your energy level:

Please rate the strength of your immune system:

What areas would you most like to support? (pick up to 3)

How often do you eat the same meal?
For example: salads, hamburgers, tacos, broccoli and beef, chicken noodle soup

Light Activity
(Minimal exertion, can talk easily or even sing)

Moderate Activity
(Heavier breathing, can talk with some effort, little to moderate sweating)

Intense Activity
(Labored breathing, difficult to talk, heavy sweating)