FLT Followup Questionnaire | 21st Century Total Wellness

Name*

Date*

At this point in the program, my primary goals and/or chief concerns are:*

Assessment of your success with the FirstLine Therapy Program

I am eating from all of the 9 food categories found on the Menu Plan Worksheet:*

Every day
75% of the time
50% of the time
25% of the time
Rarely

It is a challenge for me to eat regularly from the following food categories:*

I eat other foods not found on the Menu Plan Worksheet:*

Every day
75% of the time
50% of the time
25% of the time
Rarely

List the foods:*

I eat the recommended serving size for the foods in each category:*

Every day
75% of the time
50% of the time
25% of the time
Rarely

I am challenged to stick to the serving size with the following food categories:*

List the serving size you consume:*

I am consuming my medical food (UltraMeal drink or bar):*

2 times per day
1 time per day
Never

…and my consistency level is:*

Every day
75% of the time
50% of the time
25% of the time
Rarely

There is roughly a 3-hour interval between my meals (both meals and snacks):*

Every day
75% of the time
50% of the time
25% of the time
Rarely

The most frequent problem with timing between meals occurs here:*

Breakfast
AM Snack
Lunch
PM Snack
Dinner
Evening Snack

Breakfast*

AM Snack*

Lunch*

PM Snack*

Dinner*

Evening Snack*

Reduce Stimulant Use:

I am currently using:

Cigarettes #/day*

Wine/Beer/Liquor # servings/day*

Cups of Coffee #/day*

Cups of Tea #/day*

Soft Drinks #/day*

I am having candy, sweets or dessert:*

Daily
3-5 times per week
1-2 times per week
Other

If other, how often:*

Exercise:

I am currently doing aerobic exercise:*

Daily
3-5 times per week
1-2 times per week
Other

If other, how often:*

I am currently doing resistance (strength building) exercise:*

Daily
3-5 times per week
1-2 times per week
Other

If other, how often:*

I am currently following a stretching routine (to improve flexibility):*

Daily
3-5 times per week
1-2 times per week
Other

If other, how often:*

Stress Management:

I am getting at least 20 minutes of relaxation each day:*

Yes
No

Type of relaxation:*

I am currently getting a restful night's sleep:*

Yes
No

If no, how many hours of sleep are you getting each night?*

If you answered no to either question above, have you read the Stress Management chapter in the FirstLine Therapy Guidebook?*

Yes
No

If no, please read it and commit to applying its suggestions.

Supplement Use:

I am taking my nutritional supplements and complying with the supplement schedule:*

Every day
75% of the time
50% of the time
25% of the time
Rarely

Comments and challenges with the FirstLine Therapy Program

I am having a challenge with the FirstLine Therapy Program:*

Yes
No

If yes, is the challenge due to:*

Lack of knowledge
Lack of discipline

What is the nature of your challenge?*

Which of the following components would you like to re-evaluate?*

Balanced eating
Exercise
Stress management
Supplement use

My attitude toward the FirstLine Therapy Program is:*

Enthusiastic
Satisfied
Less than satisfied

Additional comments:*