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Reclaim Your Health 2024

How is Your Life Going? Perform this Self Assessment 

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Digestion

Answer according to your Digestive Comfort 

Question 2 of 35

1. How Often Do You Experience Digestive Discomfort (e.g., bloating, gas, indigestion)?

A

1- Never

B

2- Rarely (Few Times a Year)

C

3- Occasionally (Monthly)

D

4- Frequently (Weekly)

E

5- Constantly (Daily)

Question 3 of 35

2. How Would You Rate the Overall Comfort of Your Digestion?

A

1- Comfortable

B

2- Neutral

C

3- Uncomfortable

D

4- Very Uncomfortable

E

5- Painful

Question 4 of 35

3. How does your DIGESTION impact your life?

- What you can eat is limited
- Always need to know where the bathroom is
- Rarely eat out because of digestion
- Don’t like to go anywhere new

Pain

Answer according to your Pain Level 

Question 6 of 35

4. How Often Do You Experience Pain?

A

1- Never

B

2- Rarely ( Few Times a Year)

C

3- Occasionally (Monthly)

D

4- Frequently (Weekly)

E

5- Constantly (Daily)

Question 7 of 35

5. How Would You Rate the Intensity of Your Pain (when it occurs)?

A

1- None

B

2- Mild

C

3- Moderate

D

4- Severe

E

5- Unbearable

Question 8 of 35

6. How does your PAIN impact your life? 
For Example:

  • Unable to play with kids & grandkids
  • Don’t like to be around other people
  • Can’t Travel
  • Don’t like to go out

Tiredness & Energy Levels

Review Below and Answer Appropriately

Question 10 of 35

7. How Often Do You Feel Tired During the Day?

A

1 - Never

B

2- Rarely (Few Times a Year)

C

3- Occasionally (Monthly)

D

4- Frequently (Weekly)

E

5- Constantly (Daily)

Question 11 of 35

8. How Would You Rate Your Overall Energy Levels?

A

1- Very Low

B

2- Low

C

3- Moderate

D

4 - High

E

5- Very High

Question 12 of 35

9. How Does Your Energy Levels Impact Your Life? 

For Example:

 

  • Too Tired to Go Out
  • Too Tired to Play with Kids & Grandkids
  • Grouchy All the Time
  • Want to Sleep All Day
  • Making Mistakes at Work

Question 13 of 35

10. How Is Your Weight?

A

1- Healthy Weight

B

2 - Underweight

C

3 - Overweight

D

4- Obese

E

5- Morbidly Obese

Question 14 of 35

11. How Does Your Weight Impact Your Life?

  • Ashamed
  • Wear Baggy Clothes to Hide Body
  • Affecting Health: Blood Pressure, Cholesterol, etc
  • Difficult to Move

Question 15 of 35

12. What is Your A1C Blood Sugar Level?

A

1. Optimal (4.5-5.2)

B

2. Normal (5.2 -5.6)

C

3. Pre-Diabetic (5.7 -6.4)

D

4. Diabetic (6.5-9.0)

E

5. Vascular Issues: Heart Attack/Stroke ( 9.0+)

Question 16 of 35

13. How Does Your Blood Sugar Impact Your Life?


For Example:

 

  • Feel Guilty Eating or Avoid Eating Carbs & Sugar
  • Always Thirsty
  • Peeing a Lot
  • Feet & Legs feel Heavy
  • Tingling, Pain, Numbness
  • Tired and Letharhic
  • Cardiovascular Disease
  • Heart Attack or Stroke
  • Weight Gain
  • Kidney Disease
  • Vision Impairment

Question 17 of 35

14. How often do you feel Sad or Depressed?

A

1- Never

B

2- Rarely (Few Times a Year)

C

3- Occasionally (Monthly)

D

4 - Frequently (Weekly)

E

5- Constantly (Daily)

Question 18 of 35

15. How would you rate your overall feeling of ALIVENESS?

A

1- Feel Alive, Excited to Be Alive

B

2- Life is OK

C

3- Going Through the Motions

D

4- Feel Numb. Difficult to Function

E

5- Hopeless. Unable to Function

Anxiousness

Intense, excessive, and persistent worry and fear about everyday situations. Fast heart rate, rapid breathing, sweating, and feeling tired may occur.

Question 20 of 35

16. How Often Do You Feel Anxious?

A

1- Never

B

2- Rarely (a Few Times a Year)

C

3- Occasionally (Monthly)

D

4- Frequently (Weekly)

E

5- Constantly (Daily)

Question 21 of 35

17. How Would Your Rate Your Overall Level of Calmness?

A

1 - Zen Most of the Time

B

2- Worry a Little

C

3 - Worry Often. Sleep, Focus, Digestion Impacted

D

4 - Feel Anxious all Day, Chest Tightness

E

5- Panic Attacks

Question 22 of 35

18. How Do Your Emotions Impact Your Life?

For Example:

 

  • Don’t Want to Go Out
  • Unable to Function
  • Not Present for Kids

Stress

A Natural Human Response to a challenging or threatening situation that causes a feeling of emotional or physical tension.

It can be triggered by events or thoughts that make someone feel frustrated, angry, or nervous.

Question 24 of 35

19. How Often Do You Feel Stressed?

A

1- Never

B

2- Rarely (Few Times a Year)

C

3- Occasionally (Monthly)

D

4- Frequently (Weekly)

E

5 - Constantly (Daily)

Question 25 of 35

20. How would you rate your ability to manage stress?

A

1. Zen, Most of the Time

B

2. Busy, Irritated Easily

C

3. Often Tense, Heart Races, Headaches

D

4. Overwhelmed, Fatigued

E

5. Burnout, Exhausted

Question 26 of 35

21. How Does Your Stress Impact Your Life?


For Example:

  • Yell at Your Kids
  • People don’t want to be with you
  • Rarely Feel Happy
  • Never Satisfied

Question 27 of 35

22. Please circle the health issues that impact your daily life. If you are a caregiver for someone with any of these health issues, put a box around the health issue.

(Select all that apply)
A

Alzheimer’s Disease and/or Dementia

B

Anxiety

C

Arthritis

D

Cancer

E

Chronic Liver Disease & Cirrhosis

F

Chronic Pain

G

Chronic Respiratory Diseases

H

Diabetes

I

Depression

J

Heart Disease

K

Hypertension/High Blood Pressure

L

Inflammatory Bowel Diseases

M

Influenza & Pneumonia

N

Kidney Disease

O

Mental Health Disorders

P

Obesity

Q

Parkinson’s Disease

R

Sepsis

S

Stroke

T

Substance Abuse / Addiction

U

Other

Question 28 of 35

23. How Many Medications Do You Take Regularly?

A

1- None

B

2- One to Two

C

3 - Three to Five

D

4- Six to Eight

E

5- More than Eight

Question 29 of 35

24. How Do You Feel Most of the Time?

A

1- Love Life

B

2- Mostly Positive

C

3- Neutral

D

4- Occasionally Struggle

E

5- Struggle with Life

Question 30 of 35

25. When was the last time you felt a sense of joy? What were you doing at that moment, and how did it make you feel?

Question 31 of 35

26. What significant events, activities, or experiences you have missed due to your current health condition (e.g., significant events- birthdays, weddings, celebrations, social events, favorite hobbies, travel, etc)? 

How Do you Feel About Missing Them?

Question 32 of 35

27. If you make no changes to your current lifestyle, continue making the same choices, feeling the same way, what will your life be like five years from now? (more pain, less mobile, less energy) What will you not be able to do? What key events will you miss? How will you FEEL?

Question 33 of 35

28. Is this How You Want to Live Your Life? Why?

Question 34 of 35

29. If your health issues resolved, how would your life be different? What would you do? Who would you do it with? What is on your bucket list? How would you FEEL?

Are You Ready to Reclaim Your Health?

Thank You For Reflecting On Your Current Health Status. 

“A healthy person has a thousand wishes,

a sick person, just ONE.”

 

~ Indian Proverb

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