Habits of Health Questionnaire

Use this Health Assessment to see how your habits affect your health!

Section 1: You Are What You Eat

Note: Some questions may have multiple correct selections and will have a check box option.

What you eat and how much you eat is critical to your health. Eating more calories than you use leads to weight gain; high-glycemic foods overwork your pancreas; and foods that stimulate inflammation such as saturated fats create chaos throughout your body. On the other hand, eating lots of fruits and vegetables turns off fat storage, satisfies hunger, stabilizes blood sugar, lowers insulin, and quells inflammatory fires.

In the previous twelve months, I have:





I eat breakfast...




I eat ___ small healthy meals or snacks a day.




In general, I eat ___ of my calories after 5:00 p.m.



I eat red meat...



I eat fish that is high in omega-3...





I eat dairy products that are...



I prefer my poultry (select all that apply):




I usually like my meat or fish (select all that apply):






I eat ___ servings of vegetables a day.




I eat ___ servings of fresh fruit a day.



I get my sugar primarily from...




I eat white starches (white bread, white rice, tortillas, and pastas)...





I eat unprocessed, natural grains, cereals, and rice...



The type of fat or oil I use most often is...




I drink alcohol...






I salt my food...



I take vitamin and mineral supplements...



Section 2: On The Move

We live in a computer-driven, sedentary world. Most people are not very active. When you’re tired and overweight, it takes a lot of effort to move your body. Answer the following questions about your current activity level.

I walk...



I do aerobic activities (aerobics class, running, sports)...



I do weight resistance training...



On the weekend I usually (select all that apply)...



When outdoor activity exposes me to the sun...




At my job, I am...




During lunch and breaks (select all that apply)...




Section 3: The Inner You

Today’s chaotic schedules leave us with too much stress, and too little free time, sleep, and fun.

My job...



At work, I find myself getting upset...



My commute to work...




When I get home from work, I usually (select all that apply)...






I take part in some type of relaxation or spiritual endeavor...



The last time I had a really good laugh was...




I have ___ close personal friends.



I would describe my marriage or significant relationship as...





I get together with a group of friends for fun and companionship...



My experience with pets is best described as...



When I go to bed...



Once I fall asleep...



I wake up...






Section 4: Breathe Deep

You don’t need to be told that smoking is devastating to your health. If you’re a smoker, make quitting your very first priority.

I live...



I work...



I've smoked...





I’m exposed to secondhand smoke...




Number of packs I smoked per day:
Total Number of Years I smoked:
Section 5: Weighing You Down

Your current weight and the amount of abdominal fat you’re carrying are key health predictors. Waist circumference, waist-to-hip ratio, and Body Mass Index (BMI) can tell you whether your current habits are on target or weighing you down.Waist circumference measures your abdominal fat—both a predictor and a cause of poor health and disease. Measure your waist circumference in inches by placing it just on top of your hip—the blue line in the diagram.

Your gender:


Waist circumference (in inches):





Waist Circumference in Inches:
Hip Circumference in Inches:
Waist-Hip ratio:
Weight in Pounds:
Height in Inches:
Your BMI:
Section 6: Testing Testing

Please note: this section is OPTIONAL. If you do not have these numbers, skip this section by not filling any answers and clicking "Next" at the bottom.

Had a check-up recently? If so, your doctor may have tested your blood for four types of fats that help assess your risk for heart disease: total cholesterol, high-density lipoprotein (HDL, the "good" cholesterol), low-density lipoprotein (LDL, the "bad" cholesterol), and triglycerides. He may have also checked your metabolic health by testing your fasting blood sugar and your hs-CRP, an important measure of your current health.

If you have these numbers, you can use them to answer the following questions. If not, just skip this section by not filling any answers and clicking "Next" at the bottom —but I highly recommend you have your doctor check these levels. Just ask to have a lipid profile done at your next visit, along with blood glucose and hs-CRP.

But if you don’t have them, don’t worry. Although these numbers give us a little more information, they almost always parallel your lifestyle scores, so we can get an accurate assessment even without them. And the Habits of Health you’re about to learn are more powerful than the medications your doctor would use to treat you anyway! (Though it’s fun to get the tests done so we can watch your scores improve!)

Total cholesterol helps the body form hormones, vitamin D, and other important substances—but too much of it can clog and damage blood vessels.

Total Cholesterol:






Low-density lipoproteins (LDLs in mg/dL):






High-density lipoproteins (HDLs in mg/dL):




Triglycerides (in mg/dL):





Fasting blood glucose (sugars, in mg/dL):






High-sensitivity C-reactive protein (hs-CRP, in mg/dL):






Section 7: Start Where You Are

Any medical conditions you have at the moment are, naturally, a major factor in your current health status. But don’t be discouraged! Remember, your health status isn't fixed—it's only the starting point of your journey. By changing your health habits, we can neutralize and even eliminate many health problems and in some cases reduce or completely phase out your need for medication.

I've been to my primary care physician for my Periodic Health Examination (i.e., check-up)...



I've been diagnosed with:



Birth control: I currently ...



How many over-the-counter meds do you take (allergy, sinus, headache, etc.)?
I take a daily, low-dose aspirin of around 162 mg and:




Do you have high blood pressure?





Do you have metabolic syndrome?





Do you have polycystic ovarian syndrome?





Do you have diabetes?





Do you have thyroid condition?





I have the following advanced health conditions:






Section 8: All In The Family

Your family’s medical history reflects your genetic programming and is a big influence on your current health status and future risk. It can even affect your ability to control your weight. To find out your genetic factor (GF), add the points in the chart below for each condition that any of your parents or grandparents developed before age 60. Your GF is 1 minus that total.

For example: Your mother and grandmother had diabetes (.04 + .04) and your father had heart disease (.04), all diagnosed before age 60. Add .04 + .04 + .04, for a total of .12. Your GF is .88 (1 − .12 = .88).

My genetic factor



Take Shape For Life® makes no claim that these results are representative of all participants on the Take Shape For Life® Program. Take Shape For Life® recommends you consult with a physician before starting a weight-loss program. Average weight loss for Clients on the Optimal Weight 5&1 Plan with support is 20 lbs.

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