This Assessment focuses on understanding your current state of health and how your eating, exercise, and lifestyle habits may be affecting your overall health, weight, fitness, and aging. Your body has specific needs at this stage of life, and our goal is to help you meet those needs for optimal health and wellness. Furthermore, enjoying life after fifty requires a level of functional fitness, which includes strength, cardiovascular endurance, balance, flexibility, and a healthy body composition. This assessment will ask you about your health history, eating and lifestyle habits. It also asks you to perform 6 simple fitness assessments that highlight which areas of fitness need your attention, and that you can use as a baseline to track your progress. If you cannot complete any of the fitness tests, it is ok to indicate �incomplete�.

Please note that your information is highly confidential and would only be shared with CONEC-TIONS 50+ Essentials-Toolkit team.

Mweia Elias, the designer of this assessment will be responsible for analyzing your results and preparing your report.

MWEIA ELIAS, MS, RDN, CPT.
Registered Dietitian Nutritionist, Integrative Health Coach and Personal Trainer

Mweia is the co-founder of EMPOWER NUTRITION LTD, a consulting company that provides medical nutrition consultations, nutrition education and health coaching services to individuals, families, and businesses. Mweia is passionate about empowering people to take control of their health and use eating and exercise as medicine.

Mweia received her Master�s degree in Pharmacology & Cancer Biology from Duke University, with a certificate in Toxicology. She went on to become trained as an Integrative Nutrition Health Coach, and then furthered her studies in nutrition by completing her Master�s degree in Clinical Nutrition at New York University.

She is registered with the U.S. Commission of Dietetic Registration, an active member of the Academy of Nutrition & Dietetics, and involved in the dietetic practice groups: Weight Management, Sports Cardiovascular & Wellness Nutrition, and Dietitians in Integrative & Functional Medicine. She is also a member of the Caribbean Association of Nutritionists & Dietitians and registered with the Trinidad & Tobago Nutrition & Dietetics Board.

As a personal trainer certified by the American Council on Exercise, Mweia specializes in helping her clients take an integrative approach to reaching their goals � by combining the benefits of smart nutrition, functional training, and empowering lifestyle habits. Her goal is to empower you with the knowledge, strategies, and motivation to make healthy living practical and enjoyable.

Health & Wellness Assessment

Name*
First Last
Email*
Date of Birth*
Nutrition & Fitness Assessment
Your health, weight, and well-being are influenced by many factors. This section asks you about your eating and lifestyle habits, and asks you to perform 6 simple fitness assessments and record your results.

Fill in the answers/choices provided and if any question does not pertain to you enter “N/A”.
How would you rate your current level of health?

1 is Horrible and 10 is Awesome (Enter only the number amount.)
Please list all of your concerns about your health, eating habits, fitness, and your body?*
How, specifically, would you like your body to be different?*
What is your height (in feet & inches eg. 5'6")?*

(Enter only the number amount, as per example above.)
What is your current weight (in lbs)?*

(Enter only the number amount.)
What is your ideal weight (in lbs)?*

(Enter only the number amount.)
What is your highest adult weight over the age of 18 (in lbs)?*

(Enter only the number amount.)
What was your lowest adult weight over the age of 18 (in lbs)?*

(Enter only the number amount.)
Please List all health challenges or disease conditions that you currently have.*
Please give more details about any of your ongoing conditions (if you listed any above).*
Do you take any prescription drugs or over the counter drugs?*
List surgeries/operations you have had and their dates.*
Are you post-menopausal?*
- Yes
- No
Date of Last Menstrual Cycle (month, year)?
MM slash DD slash YYYY
Eating Habits - part 1
Tell me some more about your eating habits

Insert the answer that best reflects your eating habits and choices.
Right now, how would you rank your overall eating/nutrition habits?

1 is Horrible and 10 is Awesome (Enter only the number amount.)
Why?*
Explain why you gave yourself the rating that you did.
Please tell us in detail about any food allergies, religious or other dietary restrictions.*
Do you ever have food cravings?*
- Yes
- No
If you said yes, how often do you get these cravings?*
What foods do you crave?*
Please list your top 5 favorite foods.*
Please list all the foods you dislike or avoid.*
How much pure water do you drink per day? (in ounces or cups)*

Enter only the number amount.
List all the vitamins, minerals, and other nutritional supplements that you are taking now or within the past 3 months. Please indicate the frequency, dosage, and brand used.*
Who prepares most meals in your household?*
How many times a week do you cook?*
How often do you do food shopping? (eg. grocery, market)*
How many days per week do you eat out or buy breakfast?*
How many days per week do you eat out or buy lunch?*
How many days per week do you eat out or buy dinner?*
What restaurants do you eat at most often?*
How has your diet been different in the past?*
What eating habits do you know you need to change?*
Think about your day yesterday. Record what you ate and drank.*
Record everything that you ate and drank, the times, and estimated portion size. You can add any comments eg. How you felt or why you ate it.
Eating Habits - part 2
Tell me some more about your eating habits

Choose the answer that best reflects your level of agreement with each statement.
I have no structured meal routine from one day to the next.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
The presence of food triggers me to take a bite, taste or nibble.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I eat little during the day and am most hungry at night.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
Most of my meals are take-out or eaten in restaurants.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I have difficulty controlling my portion sizes.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
Guilt plays a big role in my diet, especially if I cheat.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
Fruits and/or vegetables don’t seem to end up on my plate or in my stomach.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I do not wake up hungry and tend to skip breakfast.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I tend to skip meals on most days of the week.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I snack during the day whether I’m hungry or not.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I eat fast and before I know it, I’ve eaten more than I should have.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I am always battling between what I want to eat and what I know I should eat.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I rarely plan my meals*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I do not eat as many fruits and/ or vegetables as I know I should.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I eat most of my food in the evening, at dinner and after dinner.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I snack on sweet treats, hungry or not.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
I find myself “stress eating” or emotional eating often.*
- Not me at all
- This is true sometimes
- This is me most of the time
- This is me definitely
Food Frequency
How often do you eat or drink each of the items listed below?
Fresh Vegetable Juice*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Pure fruit juice (nothing added)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Juice drinks*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Diet Soda*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Soda (Coke, Pepsi, Sprite, Solo, etc)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Milk*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
If you drink milk, what kind of milk do you drink?*
Beer*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Wine or Champagne*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Liquor or Mixed Drinks*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Energy Drinks*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Meal replacement/Protein Shakes*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Coffee (caffeinated or decaffeinated)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Tea (black, green, white)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Herbal Tea*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Hot or Cold Cereals (eg. Oats, Cornflakes)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Eggs*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Fresh Fruits*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Fresh Green Salad*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Cooked Green Vegetables (eg. Bhaji)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Other non-starchy vegetables*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Provisions (include Potato, Yam, Cassava)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Cooked beans or peas*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Rice*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Bread or Pasta*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Candy or Chocolate*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Cheese*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Butter, margarine, or mayonnaise*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Nuts or seeds*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Sweets/desserts*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Fish or Seafood*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Chicken or Turkey*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Red Meat (Beef, Lamb, Goat)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Sausage, processed or canned meats*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Fried Foods*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Snacks (Sweet or Salty)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
Fast Food (eg. KFC, Burgers, Chinese)*
- Never
- < 1 x per month
- 2-3 x per month
- 1-2 x per week
- 3-4 x per week
- 5-6 x per week
- 1 x per day
- 2-3 x per day
- > 3 x per day
How would you rate your stress level over the past month, on a scale of 1 to 10?

1 is Low and 10 is High (Enter only the number amount.)
What do you do for fun or to relax?*
How many hours of sleep do you get on average each day?*

(Enter only the number amount.)
Right now, how would you rank your overall level of fitness?

1 is Horrible and 10 is Awesome (Enter only the number amount.)
Why?*
Explain why you gave yourself the rating that you did.
How often do you exercise (per week)?*
- I do not currently exercise
- 1 x per week
- 2- 3 x per week
- 4 - 6 x per week
- Everyday
What type of exercise do you enjoy?*
Physical Fitness Test
What is your waist measurement (in inches)?*

(Enter only the number amount.)
What is your hip measurement (in inches)?*

(Enter only the number amount.)
Please do the exercises in the videos below.
They will play one after the other once you hit 'PLAY'. Record your results afterward. (You can play the videos in full-screen if you'd like.)
Step Test*

Beats Per Minute (Enter only the number amount.)
Plank*

Seconds (Enter only the number amount.)
Wall Sit*

Seconds (Enter only the number amount.)
Push-ups (Total)*

(Enter only the number amount.)
Flexibility*

Inches (Enter only the number amount.)
Stork Stance*

Seconds (Enter only the number amount.)
What do you want most for your health & wellness at this time? (Check all that applies)*
- Gain more energy & vitality
- Get control of my eating
- Look better
- Feel better, or feel more confident
- Get stronger and/or add muscle mass
- Shed excess weight
- Improve health condition/ prevent degenerative disease
- Get off or reduce medications
- Improve fitness and/or sports performance
Please review and ensure that all questions and areas in the relevant sections are answered.

In the areas that are not applicable to you please put NONE or N/A.

If you wish to save and return, click SAVE before leaving the page.

When you are satisfied with your responses click SUBMIT to proceed to the next questionnaire.
Understanding and Agreement (Fitness & Nutrition Assessment)*
In this assessment, I have given accurate information, to the best of my knowledge.
- Yes

Save and Continue Later

ESSENTIALS TOOLKIT HEALTH & WELLNESS ASSESSMENT

Mweia Elias, the designer of this assessment will be responsible for analyzing your results and preparing your report.

Health & Wellness Assessment

Nutrition & Fitness Assessment

Eating Habits - part 1

Tell me some more about your eating habits

Eating Habits - part 2

Tell me some more about your eating habits

Food Frequency

Physical Fitness Test

Please do the exercises in the videos below.

'CONEC' for success on the 3rd ACT stage!