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Questionnaire with Examples

September 29, 2012

I recommend that you set up your notebook with 1 question to a page. This will leave plenty of room to add and revise as you grow. We will adjust the plan each week for more and more success. Today I added examples to really help you hone in on a successful plan. Just scan the examples and only write in your binder the items that really resonate with you at a higher level.

Questions to Create a Temple Time Customized Plan – Focus Physical

1. Why are you here? Your Vision of what you are trying to accomplish. Something about the invitation got you  here. What is it?

Better health

Spiritual fitness

Continued self-healing

Sleep better

Food issues: Eat less, Eat at the right times,Stop eating when not too full, Stop eating until its gone

GI health, Not feel bloated

Get rid of aches and pains

Find the cause

Obtain a healthy weight

Manage blood sugar

Be more active

Have more energy

Run a marathon

Start putting myself on my list

Solve a particular health issue – lower blood pressure, etc

Shop for clothes with ease

Not be self-conscious about body during activities such as dancing and yoga

2. Your Goals 2 pages

Ultimate Goal – vision fulfilled – must be reasonable & trackable with date
Run a 5K by January

Lower my blood sugar by an average of 10 pts by Thanksgiving

Fit into a size 12 by Valentines day

Smaller reasonable, trackable 1 month goal leading to ultimate goal – considering special occasions coming up, etc

Walk a mile by Oct 15th

Lose 10 lb in 1 month

 3. Why are you in the shape you are in? 3 pages

What you are doing regularly or habitually that sabotages you
Health concerns that you need help navigating through
Trauma or life event when things changed
I eat whenever I want

Work is a problem-no schedule

Keeping wrong food in the house

Body out of balance-not getting foods it needs to have

Time spent on computer games

Lack of knowledge

Not being aware

Joining the group ordering out for lunch even though I have a perfectly healthy lunch

Emotionally eat when mad or frustrated

Frequently eat wrong things

Frequently overeat

Don’t know enough about nutrition

Health issue – thyroid etc

Weight gain due to medication – side effect

Divorce – One day I didn’t care anymore

Sexual assault

4. Motivates & Hinders –  2 pages – The items listed may go on the page that pertains to you. Only choose items that really resonate with you.
encourages, motivates, and helps you to reach your goals – what has been the best parts of the programs you have participated in before – activities that counteract #3
de-motivates, snags, shackles, feel like you have not control  – what has hindered your process

Exercise – exercise classes

Improved energy

Feel good

Alleviated symptoms


Good mood

Not having to cook

Accountability Partners

Focus on the positive things

God’s plan and purpose

Paradigm shift

Motivating CDs

Scripture memorization – 2 Cor 7:1

Setting boundaries

People making things and offering it to you,  

Before & After pictures

A detailed plan

Weighing & measuring food

The big picture

Set eating times

Routine Life Schedule

Restaurant eating

Food journaling: looking back on good week to duplicate

Activity journaling

Weekly encouragement

Accountability:  ___ daily  ___  weekly

Investing in program with money

Goal setting

Goal tracking

Spouse or family

Rewards for goal success

Incentives to follow plan

Competition to reach goals

Nutrition education

Weighing:  ____ daily   ____ weekly

Cooking or not knowing what to cook

New Recipes

Food Choices


Nutrition Information – great or overwhelming

Good, better, best approach

No timeline – your lifetime

Fit of clothes

Going out to eat


Counting Calories


5. Foods I love:  3 Pages 

Healthy (specific fruits, vegetable, meat, fish, beans, complex carbs such as rice, potatoes, quinoa, fats such as avocados, coconut oil, olive oil, dairy)
Unhealthy Trigger foods – have trouble stopping once start eating?
chips & dip, ice cream, cheese, chocolate, bread, pizza, candy
Restaurant foods you can enjoy with a little adjustments
(gourmet salads, Chipotle, vegetable fajitas, Picassos Restaurant, Tryst Cafe (101 & Tatum), Blue Burger, Jason’s Deli, Season 52 (Camelback & 24th St), Zs pizza (no cheese, no gluten)

6. Health Concerns:
What negative bodily symptoms do you have?

Blood sugar issues

Sleeping issues

Digestive issues – bloating, nutrition absorption issues, heartburn, indigestion, etc



Loss of muscle mass

7 . If known, what is the cause of these health concerns in #6?

Not enough enzymes to digest food

Sugar Addiction

Caffeine – (coffee, soda etc) too late at night

Eat too late at night


Stress – be specific – Too busy with family – not time for self,  High pressure time sensitive projects at work exhausts you

No exercise

8. If known, what is the solution to your health concern?
Get to bed on time

Schedule things

Create a list

Set boundaries

Decrease computer time 


Eat Less sugar

Use oils that helps for sleep

Slique appetite suppressant product

Drinking more water

9. What other information do you need to get started:

Nutritional Information

Basic health guidelines

Healthy Choices handout

Feed Your Body handout

Alkaline Foods handout

Anti-inflammatory Foods handout

Cleansing Information

Personal Chef

Personal Trainer

Personal secretary

10. Prescription Medications –  Some medications cause fatigue, weight gain, etc

Name? (synthroid, etc)


Affect goal?

Desiring to get off?

11. Over the Counter Medications – Indication of health concerns

Name? (tums, fiber, etc)


Affect goal?

Desiring to get off?

12. What supplements do you take regularly?



Affect goal?

13. Complete Start- Up Plan: This plan is dynamic and will change as needs change.

These are what you have identified for your plan:
1. An ultimate vision
2. Long term goal set
Short term goal set
3. Unhealthy behaviors – or habits &
Health issues that affect goal
4. Things that motivate you to counteract #3
Things that hinder you to enable #3.
5. Foods you love and should have in your environment
Foods you should limit.
Acceptable restaurant options for you.
6-9.  Unhealthy physical symptoms, the Cause and the Solution.
10-11. Prescription medication, over the counter medication  and how they affect your goal, supplements that you to use and how they affect your goal

12. What steps are you going to take this week to walk towards your goal to set yourself up for success? Look at your answers to the questions and think about the plan framework. Choose enough to be challenged, but not so much you are overwhelmed.

Look at motivation tools and choose which ones to enact

Shop for foods you love that are healthy

Participate in specific solutions for your health concern

Get accountability partner

Eliminate or limit foods that are unhealthy

PROVERBS 16:3  Commit your works to the Lord, And your plans will be established.
Pray this scripture daily.

Choose other scriptures that the Holy Spirit reveals.

Do you believe that you have a Godly plan?

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