Created by Michelle O’Neill and Gary Schulman as part of “The Recipe For Fitness Success”
“THE RECIPE FOR FITNESS SUCCESS”
WEEKLY SELF-EVALUATION QUESTIONNAIRE
Name: __ Date:______
Directions: Circle the number (1-5) that corresponds to your answer. Then follow the guide below each section to calculate your “Ingredient Score.” Then add all sections to get your “Total Score.”
INGREDIENT #1- PROPER NUTRITION
1.How many days of this week have you eaten breakfast?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
2.How many days of this week have you eaten a nutritious thermic meal (lean protein, starchy carb
and fibrous carb) for breakfast?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
3.How many days of this week have you eaten a nutritious thermic meal for mid-morning
snack?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
4.How many days of this week have you eaten a nutritious thermic meal for lunch?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
5.How many days of this week have you eaten a nutritious thermic meal for mid-afternoon
snack?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
6.How many days of this week have you eaten a nutritious thermic meal for dinner?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
7.How many days of this week have you eaten a nutritious thermic meal for evening snack?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
8.How many days of this week did you ignore your hunger?
none1-2days 3-4days 5-6days 7days
5 4 3 2 1
9.How many days of this week did you have junk food?
none1-2days 3-4days 5-6days 7days
5 4 3 2 1
INGREDIENT #1- SCORING
Add up the numbers you circled for all 9 answers to calculate your score for proper nutrition.
45-37Excellent
36-28Good
27-19Needs Improvement
18-9Poor
INGREDIENT #2- AEROBIC EXERCISE
10.How many days of this week did you do at least 30 minutes of aerobic exercises?
Examples: walk, run, jog, swim, cycle, etc. in your target heart rate zone.
(To calculate your Target Heart Rate Zone use the following formula:
220 - Your Age x 65% for low
85% for high
------
= Target Heart Rate Zone)
(*You can include the days that you workout with me, since I incorporate aerobic exercise.)
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
11. When performing aerobic exercisesthis week, if you felt you reached a plateau, have you
increased your intensity level, distance, and/or length of time exercising?
not at all slightlymoderately quite a bit extremely
1 2 3 4 5
12. When performing aerobic exercisesthis week, if you felt you reached a plateau, have you
changed the types of exercises you are doing to give your body a different stimulus?
(*On the days that you work out with me, I purposely vary your workouts in order to
incorporate this important principle.)
not at all slightlymoderately quite a bit extremely
1 2 3 4 5
13. How many days of this week did you do get up and move around during the course of the day just
to circulate your blood?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
14.How many days of this week did you take the stairs instead of the elevator/escalator, park further away from your destination whenever possible?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
15.How many days of this week did you walk or ride a bicycle to a destination instead of driving
whenever possible?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
INGREDIENT #2- SCORING
Add up the numbers you circled for all 6 answers to calculate your score for proper nutrition.
30-25Excellent
24-19Good
18-13Needs Improvement
12-6Poor
INGREDIENT #3- MUSCLE-BUILDING (ANAEROBIC) EXERCISE
16.How many days of this week did you do at least 30 minutes of anaerobic exercises?
Examples: resistance exercises, dumbbells, weight machines, push-ups, sit-ups, etc.
(*You can includedays that you workout with me, since I incorporate anaerobic exercise.)
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
17.When you did anaerobic exercises, how many days of this week did you truly push yourself to the
point of failure?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
18. When performing anaerobic exercisesthis week, if you felt you reached a plateau, have you
increased your intensity level, weight, length of time exercising, and/or shortened the rest period
between sets?
not at all slightlymoderately quite a bit extremely
1 2 3 4 5
19. When performing anaerobic exercisesthis week, if you felt you reached a plateau, have you
changed what you are doing to give your body a different stimulus?
(*On the days that you work out with me, I purposely vary your workouts in order to
incorporate this important principle.)
not at all slightlymoderately quite a bit extremely
1 2 3 4 5
INGREDIENT #3- SCORING
Add up the numbers you circled for all 4 answers to calculate your score for proper nutrition.
20-17Excellent
16-13Good
12-9Needs Improvement
8-4Poor
INGREDIENT #4- PROPER REST
20. How many days of this week did you do get 7-8 hours of sleep at night?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
21. How many days of this week did you take time during the course of the day to tune into
yourself and relax?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
22. How many days of this week did you take time out to do something that you enjoy?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
23.How many days of the week did you feel stressed out?
none1-2days 3-4days 5-6days 7days
5 4 3 2 1
INGREDIENT #4- SCORING
Add up the numbers you circled for all 4 answers to calculate your score for proper nutrition.
20-17Excellent
16-13Good
12-9Needs Improvement
8-4Poor
INGREDIENT #5- PROPER HYDRATION
24.How many days of this week did you drink ½ your weight in ounces of water?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
25.How many days of this week did you drink a “recovery drink” after your workout?
none1-2days 3-4days 5-6days 7days
1 2 3 4 5
26.How many days of this week did you drink soda or drinks high in sugar, high fructose corn
syrup, dextrose, sucrose, etc.?
none1-2days 3-4days 5-6days 7days
5 4 3 2 1
27. How many days of this week did you drink liquids containing sugar substitutes or sugar alcohols
(i.e. sorbitol, maltitol, glycerol), etc?
none1-2days 3-4days 5-6days 7days
5 4 3 2 1
28.How many days of this week did you drink alcohol?
none1-2days 3-4days 5-6days 7days
5 4 3 2 1
INGREDIENT #5- SCORING
Add up the numbers you circled for all 5 answers to calculate your score for proper nutrition.
25-21Excellent
20-16Good
15-11Needs Improvement
10-5Poor