Motus Health, Nutrition and Lifestyle Evaluation
We developed this assessment ourselves in order to get a wider picture of someone's health. It's an acknowledgement that there's a bit more to it than how much we weigh and how we look. It covers things like energy levels, stress and sleep, amongst others.

It works as a one-off assessment to identify both our strengths and areas for improvement. It can also help us understand some of the underlying factors that may be affecting our health and how we feel on a day-to-day basis, or even that are stopping us getting the results that we want

You will need to allow around 15 minutes to complete the assessment and some of the questions you will probably think "why do we need to know that?". We promise there's method in the madness!

Privacy: All the information you provide is private and confidential and will be processed and stored according to the most up to date GDPR Guidelines. We will never, ever, ever, ever, share or sell your data, You can read our Privacy Policy here - http://www.motustraining.co.uk/Privacy-Policy.html

1) Full Name *
Phone number & Email Address *
2) Today's Date: *
MM
/
DD
/
YYYY
3) ID:
Please use the ID provided in the email
4) Occupation/Job Title *
Social Habits
5) How many cigarettes do you smoke per day? *
20 or more
none
6) How many units of alcohol do you drink per week? *
One unit = 1/2 pint of ordinary strength beer, larger or cider, 1 small glass of wine, 1 single measure of spirit
Captionless Image
14 or more
none
Exercise
7) Taking into account all types of general activity and exercise, how active do you consider yourself to be? *
sedentary: seated job, little physical activity
extremely active: active job, exercises 4-5 times per week
Nutrition
8) How would you rate your nutritional habits? *
extremely poor
extremely good
9) Is your current nutrition working for you? *
not at all
extremely well
10) Are you following, or have you ever followed a specific “diet”? e.g. Weightwatchers, Atkins etc
many times
never needed to
Clear selection
Notes:
Nutrition Summary – please estimate intake on a typical day
11) How regularly do your eat and drink? *
I frequently skip meals
I rarely miss a meal
12) Cups of tea or coffee *
I have 6 or more cups per day, or 2+ sugars per cup
I have one or 2 cups per day, without sugar
13) Fizzy Drinks *
I have fizzy drinks more than once per day
I rarely have fizzy drinks
14) Glasses of water *
I only have 1 or 0 glasses per day
I drink 3+ litres of water per day (around 6 pints)
15) Portions of fruit and vegetables *
I often don’t eat any
I eat 7 or more portions per day
16) Sugary snacks *
I often have several sugary snacks per day
I rarely have sugary snacks
17) Savoury snacks *
I often have several savoury snacks per day
I rarely have savoury snacks
18) Oily fish *
I don’t eat any
I eat 3 or more portions per week
19) How often do you eat processed meat? (e.g sausages, bacon, burgers, hot dogs, canned meat, re-formed cooked meats, cured meats, etc.) *
I eat processed meat every day
I rarely eat processed meat
20) How often do you eat out at restaurants? *
At least once a day
Occasionally or never
21) How often do you have takeaways or fast food? *
more than once a week
Occasionally or never
22) Do you have any particular ‘weaknesses’/vices in terms of food and drink? *
Details:
23) Do you have any food allergies/intolerances or special dietary requirement (vegetarian/vegan?) *
Details:
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