There's plenty going on in Cocoa Lady's Wellness Corner. To participate tune into our podcast program to understand healthy eating, fitness tips, relaxation techniques and more. You may sign up free to receive our newsletter, and receive monthly wellness calls if you'd like. Ready set move and groove with Cocoa Lady's Dance Salutation to the Sun routine and Afro Chi Fitness techniques, which help support wellness by passively stretching before daily activities supported with good nutritional recommendations relaxation how too's. Feel free to copy off the forms posted to follow along with the program. If you would like to receive nutrition consultations or wellness support, reply to schedule with Cocoa Lady a Certified Consultant email AfroChiFitness@aol.com or call 516 408 2376.
Cocoa Lady & Home Depot, have partnered with Gold's Gym, contact for fitness discounts and more benefits.*
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Cocoa Lady & Home Depot, have partnered with Gold's Gym, contact for fitness discounts and more benefits.*
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NUTRITIONAL ANALYSIS
Releigh Nutrition/Wellness Consultant, 516 408 2376
DATE_________________
* Please check with your doctor before
beginning any diet or fitness program
Name (please print)______________________________
Contact Number
________________________________
Email
_________________________________________
Gender □
Male □ Female Age_______
Weight______ Height_______
To gain an accurate understanding of your
health, nutrition and fitness goals it is
important to record your daily activities and
nutritional intakes on a regular day.
Include all beverages as coffee, alcohol,
soda, candy bars and snacks etc. estimate
serving sizes whenever possible. Try to be
specific, e.g. instead of writing 1 cup of
milk, specify if the milk was low fat or 2%.
Explain in detail how the foods was
prepared, e.g. instead of writing 1 chicken
breast, describe how the chicken was
prepared, if fried or baked, what kind of oil
was used, if it was breaded, etc.
Daily Intake
Breakfast_______________________________________________________
______________________________________________________________
Lunch_________________________________________________________
______________________________________________________________
Dinner_______________________________________________________
______________________________________________________________
Snacks________________________________________________________
______________________________________________________________
Is the above a good representation of your
overall diet? Yes □ No □
Do you eat breakfast on a regular basis? Yes □ No □
Do you cook at home most of the time
________ or eat out regularly______?
What time do you eat your last meal at
night?_________
Would you like to Lose weight □ Gain weight □
If so, what are your nutritional goals?
__________________________________
Have you ever participated in a weight
maintenance loss/gain program before?
If so, name of?_____________________________________________
Did you complete your program and accomplish
your goal? Yes □ No □
Why do you think you did achieved or did
not achieve your goal, at that time?
Lack of commitment? □ Something or someone
distracted you?□ Too hard? □
Other □ _________________________________
Successful weight
loss is about exercise and good nutrition. Most people don't reach or maintain
their weight because they aren't on a weight loss program that combines both
exercise and nutrition.
What physical activities do you participate in
now?
_______________________________________
Which best describes your nutritional
requirements?
□ I do have specific nutritional needs
□ I am a vegetarian □ I am on a restricted diet □ I am pregnant
□ I am lactating (add 500 calories)
□ I do not have specific nutrition needs
□ I want to eat healthy, balance diet to
better manage my weight
How many glasses of purified water do you drink daily? ____
How many servings of fresh fruits/vegetables
do you eat per day?____
How many servings of low fat protein (beans,
fish, skinless chicken breast)
do you
eat per day? _______
How many complex carbohydrates (bran, whole
grains, starchy vegetables)
do you eat per day?_____
Approximately what percentage of fat makes up
your total caloric intake?____
Do you drink fruit juice every day?_______
Do you eat organic fruits and
vegetables?_______
How many cups of coffee, soda, or black tea do
you drink per day?_______
How many refined sugar items (candy bars,
donuts, cakes etc) do eat per day?____
How many containing artificial sweeteners
(gum, yogurt, etc.)__________
How many fast food items (hamburgers, hot
dogs, frozen dinners, canned foods,
French fries, etc. )do you eat per day?______
How many servings of bread pasta, and other
processed carbohydrates do you
eat per day?________
How many servings of dairy do you eat a
day?_______
How many servings of processed smoke meat
(salami, ham, wieners, sausages,
bologna, etc.) do you eat per day?__________
Do you smoke or use tobacco products?_________
How much?_______
Do you take over the counter drugs?
________________________
What kind?________________________________
Are you under the care of a physician? Yes □
No □
Number of regular bowel movements daily ____
Please check if these apply to your health
Do you have High/Low Blood Pressure □ Diabetes
□ Cardiac Concerns □
Mark any potentially harmful elements you
regularly come in contact with at
home or work:Humidity □ Mildew □ Poor
ventilation □ Air Conditioning □
Carpet
over 4 years □ High road traffic nearby □ Smog □ Florescent lighting □
Strong cleaners pesticides/bug killers□ Lawn and Garden Chemicals □
What is your stress Level 1 being low, 10
being high______
Activity level 1-10, very in-active 1 very
active 10 _______
What do you do for
relaxation?_______________________________
When was your last physical
exam____________________________
Consultant
Notes: Waist Measurements______
Weight
LBS___
BMI______RDC 1200 1500 2000 2200
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