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Health Assessment

 
SIMPLE 7 Lifestyle Tool

Score each section based on your knowledge or perception of where you fit, if you’re not sure, a guess is OK: 2 points = Ideal; 1 point = Intermediate; 0 points = poor quality) 

 
STAYING ACTIVE – physical exercise and activities strengthen your body, mind and reduce your risk for cardiovascular issues. Find exercises and activities you enjoy and can engage with at least 12 times per month and consult with your primary care physician if you are just starting. How would you assess your current status regarding exercise?        
 
EATING HEALTHY – the quality and quantity of the nutrients you put into your body will affect how your body moves, repairs, rests and functions in the long term. Consult with a nutritionist or your primary care physician to optimize your diet and reduce your lifetime risk of cardiovascular issues. How would you assess your overall nutrition?
 
WATCHING YOUR BMI – rather than worrying about weight, have your Body Mass Index (BMI) calculated. The measurements of the BMI will closely approximate the body’s percentage of fat. Ideally, your BMI should below 25 in order to significantly reduce the likelihood of cardiac health issues. If your BMI is 25-29, you are at an average risk for cardiovascular disease and heart failure, and if it is 30 or higher, your risk is elevated into the highest category. Where do you know or think you fit?
 
BLOOD PRESSURE – your blood pressure measures your vascular health by testing how hard your heart has to work to push blood through your veins and arteries; the higher the pressure, the greater the risk of damage being caused to your heart and veins (i.e. hypertension). where do you know or think you fit?           
 
BLOOD CHOLESTEROL – there are 2 types of cholesterol: low-density lipoproteins (LDL) and high-density lipoproteins. Lipoproteins are made of fat on the inside and protein on the outside. These packages are essential for your body to function properly. An unhealthy amount of LDL cholesterol, however, may clog your arteries. Ideally we'd like your total cholesterol below 200. Where do you know or think you fit?
 
BLOOD SUGAR – knowing your blood sugar is just as important as knowing your blood pressure and cholesterol. The American Diabetes Association states the approximately 86 million American’s are currently prediabetic, a condition that your physician can identify by testing your blood sugar levels. Prediabetes can be managed with diet and exercise to prevent it from becoming full blown diabetes, a condition that raises your risk for heart disease.    Give yourself a 2 if you have a good hemoglobin A1C, a one if you're prediabetic, or 0 if you have type 2 diabetes.
 
TOBACCO USE – smoking damages almost every organ in your body, and the chemicals in tobacco can harm the structure and function of your blood vessels and damage your heart. If you smoke, give yourself a 0, otherwise you are 2
 
10-14 being optimal, 5-9 being average, and 0-4 being inadequate. Research has revealed that the overall lifetime risk for heart failure among adults aged from 45-64 is only 14.4% if they fall into the optimal category, 26.8% for average, and an alarming 48.6% for those in the inadequate category (Folsom, 2015).
Your Physical Activity

Think about a typical 7-day week. How much of the following exercise do you get?
Please write the number of days of exercise and the average time (in minutes) spent exercising.

Your Tobacco Usage
Do you smoke?
Your Drinking Habits

How many of the following non-alcoholic drinks do you usually consume in a typical day? Please write the number of each type of drink you consume in the boxes below.

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Do you drink alcohol?
Add up the total number of alcoholic drinks you consume in an average week.
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Your Eating Habits

Low-fat foods 

  • Salad, fruits and vegetables

  • Pasta and rice

  • Wholegrain breakfast cereals

  • Bread

  • Lean meat

  • Fish

  • Eggs

  • Low-fat dairy products (incl. skimmed and semi-skimmed milk)

  • Low-fat spread

High-fat foods 

  • Most carry-out and fast foods (pizza, curry, Chinese)

  • Ready meals

  • Fried foods (incl. fried breakfast)

  • Crisps and chips

  • Cakes

  • muffins and biscuits

  • Donuts

  • Pasties

  • pies and sausage rolls

  • Sausages and burgers

  • Hard cheese

  • butter and mayo

  • Regular milk and milk shakes, Chocolate bars

Low-fiber foods 

  • White bread

  • White pasta

  • rice and noodles

  • Some breakfast cereals (Corn Flakes, Rice Krispies and CoCo Pops)

  • Chips and crisps

  • Potatoes without the skin

  • Ready and microwave meals

High-fiber foods 

  • Wholegrain and brown bread

  • Brown pasta and rice

  • Nuts,

  • lentils and beans

  • Most fruits and vegetables

  • Oats

  • Wholegrain breakfast cereals (Shredded Wheat, Fruit and Fiber)

  • Jacket potatoes

Low-salt foods 

  • Fruits and vegetables

  • Grilled chicken

  • Grilled fish

  • Plain pasta

  • Unsalted nuts

  • Eggs

  • Mozzarella and most soft cheeses

High-salt foods 

  • Most ready and microwave meals

  • Cured, smoked and preserved cold meats

  • Many canned soups and foods

  • Many carry-out and fast foods (pizza, Chinese, burgers)

  • Chips and crisps

  • Corn flakes

  • Shop-bought bakery products

  • White bread

  • Ketchup

  • Creamy sauces in restaurants

How often do you eat sweet, sugary foods in a typical day?
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On a typical day how many servings of fruits and vegetables do you eat?
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Your Medical Health
Which of the following medical conditions have you been diagnosed with?
Do you regularly have any of the following bodily symptoms?

Please check all of the symptoms that apply to you.

HEAD
UROGENITAL
THORAX
ABDOMEN
Which of the following conditions have affected your immediate biological family (your father, mother, sisters and/or brothers)?

Please check all that apply to you. Include all conditions you know about, even if your relative is now deceased.

Your Moods
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Thoughts that you would be better off dead or of hurting yourself in some way
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
Your Stress
Anxiety, nervousness, worry, or fear.
Feeling that things around you are strange, unreal, or foggy.
Feeling detached from all or part of your body.
Sudden unexpected panic spells.
Apprehension or a sense of impending doom.
Feeling tense, stressed, “uptight”, or on edge,
Difficulty concentrating.
Racing thoughts or having your mind jump from one thing to the next.
Racing thoughts or having your mind jump from one thing to the next.
Fears of cracking up or going crazy.
Fears of physical illnesses or heart attacks or dying.
Fears of being alone, isolated, or abandoned.
Fears that something terrible is about to happen.
Pain, pressure, or tightness in the chest.
Butterflies or discomfort in the stomach.
Restlessness or jumpiness.
Sweating not brought on by heat.
Feeling that you’re on the verge of losing control.
Fears of fainting or passing out.
Concerns about looking foolish or inadequate in front of others.
Fears of criticism or disapproval.
Skipping or racing or pounding of the heart (sometimes called “palpitations”).
Tingling or numbness in the toes or fingers.
Constipation or diarrhea.
Tight, tense muscles
A lump in the throat.
Trembling or shaking.
Rubbery or “jelly” legs.
Feeling dizzy, lightheaded, or off balance.
Choking or smothering sensations or difficulty breathing.
Headaches or pains in the neck or back.
Hot flashes or cold chills.
Feeling tired, weak, or easily exhausted.
Sleep
How often do you find you have difficulty falling asleep or difficulty staying asleep at night?
On a regular week day when you wake up in the morning and have gotten yourself out of bed and ready for the day ahead, how rested and refreshed do you feel?
Overall, how satisfied are you with the amount and quality of the sleep that you usually get?
Your Sexual Health
Are you satisfied with your sex life?
FEMALES ONLY! Please answer the following questions. Thinking back over the past 6 months...
Your Overall Health & Happiness
In general, taking all things into account, how would you rate your overall health?
In general, taking all things into account, how would you rate your satisfaction and happiness with your life?

Thanks for submitting!

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