San Juan Island Fitness Home Page
Community Healthy Weight Challenge Home Page
HEALTHY WEIGHT Challenge “CHWC” Session #3
NAME_______________________________________________
Any food allergies?
what?
Do you have a special diet?
what?
Does your doctor have any recommendations or changes about your current diet (nutritional plan) you have or have not done?
Are you willing to journal everything you eat for THE NEXT THREE DAYS?
If YES, Please do so for the next 3 days, include everything consumed, or skipped, portion size and at what time . Then bring in for evaluation.
Please use other side if you need more space.
DAY ONE DAY TWO DAY THREE
Breakfast Breakfast Breakfast
Mid morn snack Mid morn snack Mid morn snack
Lunch Lunch Lunch
Mid afternoon snack Mid afternoon snack Mid afternoon snack
Dinner Dinner Dinner
After dinner snack After dinner snack After dinner snack
Late night snack Late night snack Late night snack
Are you a “stress” or "emotional" eater?
How do you deal with “overeating”and/or “stress/emotional eating” afterwards?
Do you crave sweet or salt?
Do you crave anything else?
How much “whole foods” do you purchase?
How much “processed”?
What do you like most about your eating habits?
What would you like to change about your eating habits?
1
2
3
Do you know how many calories (or points) you should be consuming daily?
Would you like to know?
Do you count calories(or points)?
Would you try to count calories(or points)?
How many calories would you estimate you consume (or exact)?
Do you need to lose weight or want to?
Do you know what dietary proteins do?
Do you know your recommended amount of protein?
Do you know what carbohydrates do?
Do you know your recommended amount of carbohydrates?
Do you read food labels?
Are you willing to?
Do you pay attention to portion size?
Are you willing to?
Do you know the difference between dietary fats?
Ever look at how much fat you consume?
Are you willing to?
How often do you weigh yourself?
Do you normally eat before or after a work out?
What do you eat?
Do you take vitamin supplements? (Which ones?)
Do you take mineral supplements? (Which ones?)
Do you have a favorite Friday Harbor Restaurant?
What are your favorite Off Island Restaurants?
How do you usually deal with hunger (ignore till you cant any more, eat anything ect...)?
Do you have any “tips” to give to others for hunger pangs?
1
2
3
Rate (1 lest) and (6 most) of each group below that you presently, consume?
fats______ dairy______ meats/fish______veggies______ fruits______ grains
CIRCLE any of these grains that you consume:
Quinoa – Bulgur – Kasha – Wheat Berries – Farro – Millet - Buckwheat - Hemp
What time do you get up?
What time do you eat you first meal?
Do you eat regular meals?
When do you snack the most?
What are your favorite snack foods?
Do you do most of the cooking?
Do you plan your meals?
How much time do you have to prepare meals?
What time is your last meal?
What time do you go to bed at night?
What part of the day are you most likely to overeat?
What will you most likely reach for when overeating?
How much red meat do you consume per week?
Dairy per day?
Chicken per week?
Eggs per week?
How many servings of vegetables do you eat a day?
How many servings of fruit per day?
Grains per day?
Fish, any type, per week?
How many meals per day do you have (including snacks as a meal)?
about every _______ hours
Do you skip meals?
Which meal(s) are you most likely to skip?
Circle the beverages you drink during the average day:
WATER – COFFEE- -TEA – SODA – ALCOHOL – FRUIT JUICE – MILK – OTHER________________________________________________________
Are you willing to make substitutions like a squeeze of lemon in water instead of soda pop or almond milk instead of cows milk (ect…)?
Are you willing to consume foods in its most natural form instead of processed in any way? (like an apple instead of an apple pie)