Readiness Assessment

Name *

First Name

Last Name

Significantly modify your diet

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2

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4

5

Take several nutritional supplements each day

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2

3

4

5

Keep a record of everything you eat each day

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2

3

4

5

Modify your lifestyle(e.g., work demands, sleep habits)

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2

3

4

5

Practice a relaxation technique

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3

4

5

Engage in regular exercise

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2

3

4

5

How confident are you of your ability to organize and follow through on the above health-related activities?

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2

3

4

5

At the present time, how supportive do you think the people in your household will be to your implementing the above changes?

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5

How much ongoing support (e.g., telephone consults, email correspondence) from me would be helpful to you as you implement your personal health program?

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5