1. Energy level throughout the day:

I can easily work out and do all daily activities with ease.

When I wake up in the morning, I feel refreshed and with plenty of energy for most of the day.

I have enough energy for about half the day. I need to take a nap daily

I feel drained of energy for most of any given day

I'm completely burnt out. I can barely get out of bed, much less do anything

2. The pain I feel is in my:

head

neck

shoulders

back

abdomen

hips

legs

feet

3. I feel safe ...

at all times

most of the time. Every once in a while, I'll find myself in a situation or place that is not safe and will need to leave.

about half of the time. There are some things that need to be resolved in order for me to feel safe more frequently.

occasionally. Most of the time I am scared that I may be hurt.

never. I am scared for my life.

4. Smoking is ...

not something I do in any amount, nor am I exposed to second hand smoke.

not something I do, but I am occasionally exposed to second hand smoke.

something I do occasionally, but am not addicted to it.

something I do more than I should, although it could be a lot worse.

something that I am addicted to.

5. I feel physically energetic ...

always

most often

frequently

sometimes

rarely

never

6. Drinking alcohol is ...

not something I do in any amount.

not something I do regularly, although I may have a little at parties and other gatherings.

something I do frequently, but I never drink enough to get drunk.

something I do too much. I do get drunk occasionally, but do not get violent.

something I have a serious addiction to.

7. My overall health and fitness level:

8. I meditate ...

daily

a few times a week

once a week

once a month if I'm lucky

never

9. Fitness to me is ...

very important

somewhat important

not that important

unimportant

10. I am ___________ with my fitness level:

very satisfied

generally satisfied

somewhat satisfied

somewhat dissatisfied

generally dissatisfied

very dissatisfied

11. The foods & drinks I consume are ...

about as nutritious as they could be!

are mostly nutritious. I have a few vices, but I keep it less than 15% of my total intake.

somewhat nutritious. About half of what I consume is probably good for me.

mostly not good for me. Sometimes I'll eat something healthy.

mostly junk food. My diet is about as bad as it could be.

12. On a scale of 1- 10, what is the intensity of the pain I have

13. I am pain free ...

always

most often

frequently

sometimes

rarely

never

14. When I wake up in the morning...

I am ready to jump out of bed and get moving

I am awake and getting out of bed willingly

I am not wanting to get out of bed, yet I do

I am really dragging my feet to force myself out of bed

I don’t want to get out of bed at all

I don’t get out of bed today I sleep in

15. When I think about eating good foods, I ...

look forward to it with joy because eating good foods feels really good to me

want to do it and have had positive experiences, but have not been that consistent.

think “Maybe I should try this and see what happens.”

think “Well I know I should, but do I have to?”

cringe at the thought

16. Rate Your Sleep from 1-5

5 - My Sleep is Deep. I get the right amount of sleep and I wake feeling refreshed

4 - I sleep pretty good most of the time

3 - I sleep well about half of the time

2 - I mostly do not sleep well

1 - My sleep is horrible. Its a huge issue for me

17. My health is:

improving significantly.

improving slightly.

staying about the same.

getting worse.

deteriorating at a rapid pace.

18. The level of stress I feel on a weekly basis is:

none.

is minimal.

is about what the average person would feel.

is difficult to manage.

is full blown anxiety on a regular basis.

19. I rely on prescription meds:

never

occasionally when needed

now on a regular basis

more than most people. I depend on them for my health.

as an addiction. I depend on them for my survival.

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