Initial Assessment - 100-Day Plan

1

Basic Information

Demographic and anthropometric data

Full Name *

Email *

Age (years) *

Weight (kg) *

Height (cm) *

Waist Circumference (cm)

Optional - measure at belly button level

Life Stage

3

Lifestyle Habits

Diet, physical activity and tobacco use

🥗 Diet

Servings of fruits and vegetables per day:

Whole grains (bread, pasta, brown rice):

Processed food/fast food per week:

🏃‍♀️ Physical Activity

Minutes of moderate/vigorous exercise per week:

Moderate: brisk walking, swimming, dancing. Vigorous: running, tennis, HIIT

🚭 Nicotine Exposure

Smoking status:

😴 Sleep

Average hours of sleep per night:

4

Health Metrics

Blood pressure, cholesterol and glucose

💓 Blood Pressure

Systolic (mmHg):

Diastolic (mmHg):

If you don't know your values, leave them blank

🩸 Cholesterol

Total (mg/dL):

LDL (mg/dL):

HDL (mg/dL):

🍬 Glucose

Fasting glucose (mg/dL):

HbA1c (%):

Initial Assessment
100-Day Wellness Plan

Basic Information

Medical History

Lifestyle Habits

Health Metrics

Initial Assessment 100-Day Wellness Plan

Basic Information

Medical History

Lifestyle Habits

Health Metrics

Initial Assessment
100-Day Wellness Plan