Immediate Symptoms, Problems and Concerns
Diets
Exercise Programs
Practitioners or Web Sites Consulted
Long Range Health Goals and Concerns
Notable Injuries, Illnesses, Surgeries
Diagnostic Studies: Blood, Scans, X-rays,
Endoscopies
Family Diseases or Conditions
Stressful Things Affecting You, Your
Family or Friends
Up-to-date on Immunizations?
Screening Exams for Cancer, Diabetes, etc.
Do you eat breakfast daily?
Do you wear seat belts?
Is your body fat percentage 15% if an adult male or 20% if female?
Have you had a diptheria-tetanus booster
shot within 10 years?
Are green & yellow vegetables and the
cabbage family (Brassicas) a frequent part of your diet?
Do you drink 5-6 glasses of water daily?
Do you avoid saturated dietary fats?
Do you include a lot of fiber in your
diet?
Do you include 30 minutes of continuous
and strenuous (aerobic) exercise in your schedule at least 5 days a week?
Do you wake rested in the morning most of
the time?
Are you able to describe your diet as
predominately vegetarian?
Do you have mutually supportive relations
with people in your family, your community and at work?
Do you observe regular spiritual practices
in your daily life?
Are you able to take time off when you
need to? Do you do it?
Do you laugh heartily, sob when you cry
and have total body orgasm?
Do you enjoy recreation regularly in your
life?
Do you avoid eating within three hours of
bed time?
Do you have periodic checkups for
glaucoma, prostate cancer, cervical cancer, breast cancer, and blood in the
stool, as appropriate for age and sex?
Do you do self-examination for
abnormalities of your skin, your gums, your breasts and your testicles?
Are you aware of health risks you may have
due to family history or your own daily life style habits?
Do you feel your daily work is productive
and meaningful to you and for others?
Do you smile more than you frown?
Do you exchange touches and hugs with
others daily?
Do you listen and talk in equal measure?
Do you know your feelings and express them
easily?
Does your food digest comfortably?
Do you drink liquids with your meals?
Is your workplace comfortable?
Do your toes, chest and abdomen have
freedom from restriction in their movement?
Are your airways (nose, mouth, throat and
lungs) smoke free?
Do you use alcohol infrequently or not at
all?
Do you abstain from mind altering drugs?
Caffeine?
If approaching middle age and female, have
you considered calcium supplements, regular exercise and estrogen replacement
therapy?
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Would you like to
take a Life Style Assessment Questionnaire?
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