*Please complete the form by choosing the right option as applied to you:

If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by choosing the right option as applicable to you: 1 for "mild or rarely occurring", 2 for "moderate or regularly occurring", for "severe or often occurring", or "does not apply" if the symptoms/statements does not apply to you.

lifestyle assessment e-form

*what are the major causes or factors of your stress? rate all that apply on a scale of 1 (low) to 10 (high):

do you awaken feeling rested?

do you snore?

do you enjoy your work?

do you smoke?

if "no", does anyone in your household or workplace smoke?

how many hours do you spend daily, on average:

do you go on vacation regularly?

do you actively participate in any spiritual discipline (church, religious group, meditation, etc.)?

medical history:

are you currently taking any medication?

have you ever been:

family history:

hereditary diseases: use "f" for father, "m" for mother, "s" for siblings, "g" for grandparent, "o" for other(s):



dietary habits:

how many times a day do you eat:

do you eat meals:

how many 1/2 cup servings of each do you typically eat in a day:

provide examples of your typical meals:

do you eat or use (indicate "1" for "rarely", "2" for "regularly", "3" for "often")

please indicate how many cups of the following you drink per day:

client statement:

i understand and acknowledge that the services provided are at all times restricted to consultation on the subject of health matters intended for general well-being and are not  meant for the purposes of medical diagnosis, treatment or prescribing of medicine for any disease, or any licensed or controlled act which may constitute the practice of  medicine. this statement is being signed voluntarily.

you are on your way to wellness!