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Lifestyle Assessment Questionnaire


Client Name: Nina Muller Date: Oct 28,12
This portion of the intake will help greatly in our study of your present health and will assist us in choosing an appropriate direction to take in working toward your optimum health. Please answer each of the following questions: Do you eat, drink or use: Circle answer Water (WHAT TYPE) - Tap Distilled Spring Reverse Osmosis candy fried foods chew tobacco luncheon meats carbonated drinks fast foods margarine chew gum coffee refined sugars saccharine (sweet & low) aluminum pans microwave

How many cups/bottles/glasses do you drink, on average, per day: coffee______ tea___1____ water___4____ milk(2%)_____ milk(skim)_______ fruit juice_____ soft drinks(diet)_____ soft drinks (reg)_____ vegetable juice____ herbal tea__1___ beer_______ wine _______ liquor______

How often do you have an alcoholic beverage?_________never_________________ Have you ever been treated for alcoholism? Yes_______ No__________ Do you smoke? Yes____ No_____ (if yes, how many cigarettes a day?)_______ Have you ever smoked? ___NO__ For how long?__________ Does anyone smoke in your household?_no __ Your workplace?___no_ Do you use any recreational drugs?Yes_____ No_____(If yes, pls indicate type & frequency of usage) ______________________________________________________________________________ ______________________________________________________________________________ Have you ever been treated for pharmaceutical or recreational drug dependence?___________ How many hours a day do you watch television?______ How many hours do you read?_________ How many hours do you spend in front of a computer?__________

2 What do you do for recreation? What are your main interests/hobbies? Exercise Regime: Yes/No Type and Frequency: Activity level: moderate, active, athletic

What is your Occupation? (indicate # of hours worked weekly/ satisfaction level/ stress level)

Do you take vacations regularly? When was your last vacation? Energy Levels? Stamina: Fatigue During What Time Of Day? What is your regular routine within 2 hours of going to bed? When do you go to bed and get up each day? Do you wake up during the night? If Yes, how often and can you get back to sleep easily? Is your room pitch dark? Do you awaken feeling rested? Do you take naps? Describe your current stress level? Circle answer Minimal Average Considerable Unbearable

What is/are main stressor(s) in your life? Circle answer(s) Health Financial Job-related Interpersonal Unfulfilled Self-expectations Family members

Marriage Spiritual

Do you participate in any spiritual disciplines or belong to a church or religious group?