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4. How many eight-ounce glasses of water do you drink daily? a) 0-3 b) 3-6 c) 6-9 d) 10 or more |
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5. The main source of the water you drink is: a) Municipal b) Home well or stream c) Home carbon filtered/reverse osmosis d) Bottled or delivered e) Distilled f) Carbonated mineral water |
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6. On a scale from 1-10 (1 being the lowest, 10 being the highest), how would you rate your overall energy level? a) 0-2 b) 3-5 c) 6-8 d) 9-10 |
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7. How often do you have a bowel movement? a) Less than once a day b) Once a day c) 2-3 times a day d) More than 3 times per day |
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8. Do you smoke or chew tobacco products? a) Never b) No, but I’m exposed to second-hand smoke. c) Occasionally d) Regularly e) Used to, but quit |
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9. How often do you consume an alcoholic drink, e.g. a bottle of beer, a glass of wine, an ounce of hard liquor? a) Never b) Occasionally c) Regularly d) I’m a recovering alcoholic. |
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10. Do you use recreational drugs? a) Never b) Occasionally c) Regularly d) Used to, but quit |
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11. How many prescription medications do you regularly take? a) None b) 1-2 c) 3-5 d) 5 or more |
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12. Concerning your weight, do you consider yourself to be: a) Underweight b) Just right c) Overweight d) Obese |
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13. Concerning any type of body pain, do you experience: a) Longstanding/chronic pain b) Recent /acute pain c) No pain most of the time |
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14. Do you suffer from any chronic diseases? a) Yes, and it interferes with my daily life. b) Yes, but it does not interfere with my daily life. c) No |
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15. I am satisfied with the frequency and quality of my sexual activity: a) Not applicable b) Rarely c) Occasionally d) Regularly |
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16. I practice safe sex with only one partner: a) Rarely b) Occasionally c) Regularly d) Always |
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17. Are you aware of your current blood pressure and cholesterol readings? a) Yes, and they are normal b) Yes, and they are abnormal c) No, I am not aware |
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GENETICS | |
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18. When considering your immediate family -- grandparents, parents, and siblings -- how is their general health overall? a) Excellent b) Good c) Fair d) Poor e) Extremely poor |
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NUTRITION | |
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19. Concerning your meals, most are: a) Takeout/fast food b) Restaurant c) Packaged, frozen, canned food d) Fresh, unprocessed, home cooked |
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20. How often do you eat processed, fast, or junk foods? a) Rarely b) Occasionally c) Regularly |
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21. How often do you eat deep-fried, microwave, or packaged processed foods? a) Rarely b) Occasionally c) Regularly d) Frequently |
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22. How often do you consume raw or lightly cooked vegetables? a) Rarely b) Occasionally c) 1 to 2 times daily d) 3 to 4 times daily e) More than 5 times daily |
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23. How often do you consume raw fruit? a) Rarely b) Occasionally c) 1 to 2 times daily d) 3 times or more daily |
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24. How often do you consume super foods such as sprouts, fresh-juiced drinks, or powdered green drinks? a) Never b) Rarely c) Occasionally d) Regularly |
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25. How often do you eat beans/legumes such as black, pinto, kidney, or lentils? a) Rarely b) Occasionally c) Regularly |
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26. How often do you consume unprocessed raw nuts and seeds? a) Rarely b) Occasionally c) Regularly |
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27. How often do you consume beverages such as coffee, regular tea, pop, powdered/instant drinks, or sweetened fruit drinks? a) Rarely b) Occasionally c) Regularly d) Frequently |
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28. What type of flour/grain products do you consume? a) Mostly white-flour products b) Mostly whole-wheat products c) Mostly rice d) Mostly alternative grains, e.g. spelt, millet, kamut, rye, oats, quinoa |
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29. What types of oils do you use most often in your diet? a) Butter b) Margarine c) Lard d) Flax/fish oil e) Virgin olive oil f) Commercial vegetable oil g) Not sure |
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30. What type of sugar or sweetener do you most commonly use? a) Sugar b) Artificial sweetener c) Honey d) Maple syrup |
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31. On average, how often do you consume sugar/sweetener? a) Rarely b) Occasionally c) Regularly d) Frequently |
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32. Concerning red meat, I mostly eat: a) Organically raised b) Wild c) Commercially raised d) Little or no red meat |
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33. Concerning white meat, such as chicken, turkey, and pork, I mostly eat: a) Organically raised b) Commercially raised c) Little or no white meat |
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34. Concerning fish, I mostly eat: a) Wild b) Commercially farmed c) Little or no fish |
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35. I consider my salt consumption to be: a) Light b) Medium c) Heavy |
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36. I do not skip meals and consider my diet to be balanced: a) Most of the time b) Some of the time c) Rarely |
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37. I am aware of the seasonal availability of foods and eat in a varied and rotated manner: a) Most of the time b) Some of the time c) Rarely |
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38. My understanding and knowledge of the amount and type of food additives, colorings, and preservatives I consume is: a) High b) Medium c) Low d) Not aware |
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39. I take time to eat, chew my food well, and relax during my meals: a) Rarely b) Occasionally c) Regularly |
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40. I use nutritional supplements/herbs: a) Rarely b) Occasionally c) Regularly |
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41. I am aware of the safe intake levels for supplements/herbs and optimal consumption times: a) Yes b) Somewhat c) Not Sure d) No |
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42. How often do you fast or practice other detoxification methods? a) Rarely b) Occasionally c) Regularly |
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EXERCISE | |
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43. How would you rate your overall level of physical fitness? a) Excellent b) Good c) Fair d) Poor |
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44. Do you exercise: a) Year-round b) Seasonally c) Occasionally d) Rarely |
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45. Please indicate how long you have been exercising on a regular basis: a) I do not exercise regularly. b) Less than 6 months c) 6 months-2 years d) Over 2 years |
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46. How long does a typical exercise session last for? a) Less than 10 minutes b) 10-20 minutes c) 21-30 minutes d) 31-60 minutes e) Over an hour |
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47. How many days per week do you engage in continuous cardiovascular exercise for 20 minutes or more? a) 0 b) 1-3 c) 4-7 |
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48. On average, how would you rate your effort when performing your cardiovascular exercise? a) Little effort b) Moderate effort c) Maximal effort |
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49. How many days per week do you participate in strength training exercises? a) 0-1 b) 2-4 c) 5-7 |
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50. How many days per week do you engage in exercises that promote flexibility, e.g., “stretch-and-hold” exercises, Tai Chi, Yoga? a) Never b) 1-3 times per week c) 4-7 times per week |
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51. Are you able to carry out your daily tasks -- e.g. laundry, vacuuming, grocery shopping, mowing the grass, house cleaning -- without feeling extremely overexerted or exhausted? a) Most of the time b) Occasionally c) Rarely |
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52. How would you describe your activity level during the day? a) Not active b) Somewhat active c) Active d) Very active e) Labour intensive |
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ENVIRONMENTAL HEALTH | |
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53. Is your primary residence located near any of the following: a major highway or street; an airport; heavy industry; a landfill or incinerator; an orchard or farm; high-tension wires or radio/telephone/radar antennas? a) None of the above b) One of the above c) Two of the above d) Three of the above e) Four of the above f) Five of the above g) All of the above |
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54. Do any of the following descriptions apply to your home: it is more than 40 years old; it is new or newly renovated; it has an attached or underground garage; it has a moldy basement or windows; it has natural-gas appliances; it houses indoor pets? a) None of the above b) One of the above c) Two of the above d) Three of the above e) Four of the above f) Five of the above g) All of the above |
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55. Do any of the following descriptions apply to your workplace: you experience significant exposure to chemicals, dust, fumes, noise, etc.; it has poor air quality; it is new or newly renovated? a) None of the above b) One of the above c) Two of the above d) All of the above |
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56. How much fresh, open air and moderate sunshine exposure do you get? a) None b) Little c) Moderate d) Lots |
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57. Does your occupation require shift work? a) Yes b) No c) Occasionally |
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58. What is the total number of hours you drive your car, ride public transit, or fly per week? a) 0-3 b) 4-10 c) greater than 11 |
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59. What is the number of combined hours per week that you use the computer, telephone, or television? a) 0-5 b) 6-15 c) 15-25 d) 30-60 e) More than 60 |
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EMOTIONAL HEALTH | |
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60. I feel my life is balanced between work, rest, and play: a) Most of the time b) Some of the time c) Rarely |
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61. I feel I have a healthy relationship with my food: a) Yes b) No c) Sometimes |
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62. In appropriate situations I can be spontaneous: a) Regularly b) Occasionally c) Rarely d) Never |
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63. I understand and know the need to play, and in my life I: a) Regularly play b) Occasionally play c) Rarely play d) Never play |
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64. In the course of an average day, I laugh: a) Rarely b) Occasionally c) Regularly |
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65. I use some form of relaxation, meditation, or prayer: a) Rarely b) Occasionally c) Regularly |
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66. Do you have a spiritual practice or faith? a) Yes b) No c) Not sure |
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67. I feel safe and secure in my home and neighborhood: a) Yes b) No |
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68. I have people whom I am close to and with whom I can share my feelings: a) Rarely b) Occasionally c) Regularly |
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69. I experience love and affection in my life: a) Rarely b) Occasionally c) Regularly |
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70. Have you personally ever experienced or witnessed physical, sexual, verbal, or emotional abuse? a) Never b) Rarely c) Occasionally d) Regularly |
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71. I have been able to understand, process, and release previous negative experiences: a) Yes b) No c) Unsure |
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72. I experience the emotion of joy in my life: a) Rarely b) Occasionally c) Regularly |
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73. Concerning stress, would you say your stress level is: a) High b) Medium c) Low |
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74. When you encounter a stressful situation, do you: a) Capitulate/surrender b) Withdraw c) Compromise/work it out d) Refuse to compromise |
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75. How often do you worry? a) Rarely b) Occasionally c) Frequently |
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76. Our primary emotions include sadness, fear, anxiety, joy, and anger. On any given day, are you aware of these four emotions and able to process them/express them so that your suppression of them does not have a negative effect on your day? a) Rarely b) Occasionally c) Regularly d) Not sure |
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77. I allow myself to cry when experiencing sadness: a) Never b) Occasionally c) Frequently d) Always |
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78. Do you have a sense of feeling trapped and hopeless/scared in your life today? a) Yes b) No c) Sometimes |
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79. Do you suffer from a mental illness, such as depression, chronic anxiety, bipolar disorder, schizophrenia, etc.? a) Yes b) No c) Not sure |
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80. Of the following character/personality traits, which one most describes you? a) Driven/pressured to succeed b) Perfectionist/need control c) Stubborn/uncompromising d) Laidback/relaxed e) Prioritize other's needs over one’s own f) Pessimistic/negative g) Optimistic/positive h) Highly motivated/empowered |
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ATTITUDE | |
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81. I have experienced greater health than illness in my life: a) Yes b) No |
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82. I am satisfied with my life as a whole: a) Yes b) No |
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83. I believe that I can make a difference in my health and well-being: a) Yes b) No |
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84. I see illness as a process that helps me change and grow: a) Yes b) No |
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