Health Assessment

First Name

Last Name

Age

About You

How would you best describe your race and ethnic group?
We’d like to know about your racial and ethnic origins. The reason for this is that some diseases and
illnesses are more common in people with certain backgrounds. Please check ONE answer only

WHITE

White American

Other White Background

MIXED RACE

SPANISH, HISPANIC OR LATINO

Mexican, Mexican American, Chicano

Puerto Rican

Cuban

Other Spanish, Hispanic or Latino origin

BLACK OR AFRICAN AMERICAN

African

Caribbean

Other Black Background

RACE & ETHNIC GROUP

I prefer not to answer this

Heart disease kills 10 times more women every year than breast cancer, so it is vitally important to evaluate for heart disease risks. Routine testing, whether blood work or questions, misses 82% of women at risk.

This is a short profile that has been shown to be very effective at assessing your individual risk. Remember, we are not after normal, we are after optimal!

(Please add up your points for each answer and put the total in the box at the bottom of this section)

How old are you?

Less than 65 years old (1 point)

Greater than 65 years old (4 points)

Do you have a family history of early cardiovascular disease (a male relative affected before age 55 or a female relative affected before age 65)?

No (0 points)

Yes (4 points)

What is your waist circumference?

If you’re a women: Less that 35 inches (0 points)

If you’re a woman: 35 inches or more (4 points)

What is your blood pressure? (Check all answers that apply)

Less than 120/ 80 (0 points)

Taking blood pressure medication (2 points)

120/ 80 to 139/ 89 (3 points)

140/ 90 or higher (4 points)

Don’t Know (4 points)

What is your total cholesterol level? (Check all answers that apply)

Less than 160 mg/ dL (0 points)

Less than 200 mg/ dL (1 point )

Taking cholesterol medication (2 points)

Greater than 200 mg/ dL (3 points)

Don’t know (3 points)

What’s your weight range?

Underweight (2 points)

Average (1 point)

Overweight (3 points)

Obese (4 points)

What is your HDL (good) cholesterol level?

Less than 60 mg/ dL (3 points)

60 mg/ dL or higher (0 points)

Don’t know (3 points)

What is your resting pulse?

Less than 60 beats per minute (0 points)

Less than 75 beats per minute (1 point)

More than 75 beats per minute (2 points)

Don’t Know (2 points)

What is your LDL (bad) cholesterol?

How much exercise do you get?

At least 30 minutes, 5 to 7 days per week (0 points )

At least 30 minutes 2 to 4 times per week (1 point )

30 minutes, once a week or less (2 points)

I do not exercise (4 points )

Do you drink regular or diet soft drinks?

Never (0 points )

Rarely drink soda (diet or regular) (1 point)

Once a week (diet or regular) (2 points )

More than once a week (3 points)

Which of the following best describes your triglyceride level?

Less than 100 mg/ dL (0 points)

Less than 150 mg/ dL (1 point)

More than 150 mg/ dL (3 points)

Don’t know (3 points)

Do you have diabetes or high blood sugar?

No (0 points)

Yes, I’m prediabetic (3 points)

Yes, I’m diabetic (4 points )

I haven’t had my blood sugar tested (4 points)

Do you have bleeding gums? (Check all answers that apply.)

Never (0 points)

Yes, when I brush or floss (2 points)

I usually don’t floss my teeth (2 points)

Which of the following best describes your sleep patterns?

I sleep soundly 6-8 hours a night (0 points)

I sleep restlessly for 6-8 hours a night (2 points)

I sleep less than 6 hours or more than 9 (3 points)

Do you snore?

No (0 points )

Yes, occasionally (1 point )

Yes, frequently and loudly (3 points)

Yes, and I have sleep apnea (4 points)

Do you have rheumatoid arthritis or any other inflammatory disease such as psoriasis or lupus?

No (0 points)

Yes (4 points)

Do you smoke?

No (0 points)

I used to smoke, but have quit for at least 5 years (1 point )

I used to smoke, but quit less than 5 years ago (2 points)

I am exposed to secondhand smoke regularly (3 points)

I smoke or I use smokeless tobacco products (4 points )

Do you watch the amount of carbs in your diet?

I limit my simple carbohydrate intake (0 points)

I know to balance my carb/ protein balance (1 point )

I never watch my carbohydrates (2 points)

The majority of my diet consists of carbs (4 points)

Did you experience high blood pressure or gestational diabetes during pregnancy?

No (0 points )

Yes (4 points )

Do you spend eleven or more hours a day sitting?

No (0 points )

Yes (4 points )

Have you been checked for vitamin D deficiency?

My vitamin D level is between 50-60 (0 points )

My vitamin D level is less than 30 (3 points )

I do not know my vitamin D level (3 points)

Do you have a history of migraine headaches?

No (0 points )

Yes, with no migraine aura (2 points)

Yes, with a migraine aura (3 points)

How would you characterize your ability to cope with stress?

I’m usually pretty laid back (0 points )

I have healthy ways to cope with stress (1 point)

Sometimes people say that I seem stressed (2 points)

I feel stressed and anxious most of the time (4 points)

Please add up the points from each answer

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.

Vigorous physical activities (Like heavy lifting, digging, aerobics or fast cycling)

Moderate physical activities (Like carrying light loads, cycling at regular pace or doubles tennis)

Walking for at least 10 minutes (Includes walking at work, home or for any exercise or leisure)

Your Tobacco Usage

Do you smoke?

Yes, I currently smoke

No, I gave up less than 10 years ago

No, I gave up more than 10 years ago

No, I’ve never smoked or chewed tobacco (if you select this answer, skip the next question)

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.

Screen Shot 2021-05-26 at 1.40.02 PM.png

Number of cups of coffee

Screen Shot 2021-05-26 at 1.41.35 PM.png

Number of cans of soda

Screen Shot 2021-05-26 at 1.42.28 PM.png

Number of cans of energy drinks

Screen Shot 2021-05-26 at 1.43.11 PM.png

Number of cups of milk?

Screen Shot 2021-05-26 at 1.41.10 PM.png

Number of cups of tea

Screen Shot 2021-05-26 at 1.42.01 PM.png

Number of cans of diet soda

Screen Shot 2021-05-26 at 1.42.50 PM.png

Number of cups of water?

Screen Shot 2021-05-26 at 1.43.57 PM.png

Number of cups of juice?

Do you drink alcohol?

Yes

No (if you select this answer, skip the next question)

Only very occasionally, less than one drink a week (if you select this answer, skip the next question)

Add up the total number of alcoholic drinks you consume in an average week.

Screen Shot 2021-05-26 at 1.49.03 PM.png

Glasses of Beer (12oz)?

Screen Shot 2021-05-26 at 1.49.45 PM.png

Glasses of White Wine (5oz)?

Screen Shot 2021-05-26 at 1.50.18 PM.png

Glasses of Red Wine (5oz)?

Screen Shot 2021-05-26 at 1.51.57 PM.png

Number of Mixed Drinks (1.5oz)?

Your Eating Habits

When choosing foods, do you tend to eat high-fat or low-fat items? (1 = Low fat foods, 5= High fat foods)

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

When choosing foods, do you tend to eat high-fiber or low-fiber items? (1=Low fiber foods, 5= High fiber foods)

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

When choosing foods, do you tend to eat high-salt or low-salt items? (1=Low salt, 5= High salt)

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

Screen Shot 2021-05-26 at 2.02.41 PM.png

Screen Shot 2021-05-26 at 2.04.04 PM.png

Your Medical Health

Do you regularly have any of the following bodily symptoms?

Please check all of the symptoms that apply to you.

UROGENITAL

Frequent Need to Pass Urine (including at night)

Incontinence

Burning or Stinging on Passing Urine

Blood in Urine

THORAX

Shortness of Breath

Palpitations (fast-beating heart)

Cough

Chest Tightness

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

Bowel cancer

Breast Cancer

Ovarian Cancer

Heart Disease (only if it started before the age of 65 years in a female relative)

Heart Disease (only if it started below the age of 55 years in a male relative)

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

Your Stress

Thinking about your life, on average how stressed and under pressure do you feel? Try to think about all areas of your life, including your work life, home life and family life, before you answer the question. (1=Low stress, 5= High stress)

How are you coping with the stress and pressure in your life? (Please check ONE answer only.)

Looking back over the last 3 months, how often have you felt anxious or nervous for no good reason? (1= not at all, 5= all the time)

Looking back over the last 3 months, how often have you felt sad, miserable or depressed? (1=not all all, 5= all the time)

Here is a list of common symptoms of depression. How much has each one bothered you during the past week, including today?

Have you been feeling sad or down in the dumps?

Do you feel worthless or think of yourself as a failure?

Do you get self-critical and blame yourself for everything?

Have you been feeling resentful and angry a good deal of the time?

Do you feel overwhelmed and have to push yourself hard to do things?

Have you lost your appetite, or do you overeat or binge compulsively?

Have you lost your interest in sex?

Do you have thoughts that life is not worth living or think that you might be better off dead?

Does the future look hopeless?

Do you feel inadequate or inferior to others?

Do you have trouble making up your mind about things?

Have you lost interest in your career, your hobbies, your family or your friends?

Do you think you’re looking old or unattractive?

Do you suffer from insomnia and find it hard to get a good night’s sleep? Or are you excessively tired and sleeping toomuch?

Do you worry a great deal about your health?

How would you describe the support you are able to get from other people during times of stress? Think about people who are close to you and you know will help and listen when times are tough (1=I have no support, 5= I have plenty of support)

Sleep

How many hours of sleep do you get on atypical weekday/work-night?

How many hours of sleep do you get on atypical weekend/non-work night?

How often do you find you have difficulty falling asleep or difficulty staying asleep at night?

I have these problems most nights

I have these problems at least 2 or 3 times a week

I have these problems about once a week

I occasionally have these problems, but less than once a week

I virtually never have these sort of problems

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?

Your Work

Your Sexual Health

Are you satisfied with your sex life?

FEMALES ONLY! Please answer the following questions. Thinking back over the past 6 months...

Are you satisfied with your level of sexual desire or interest?

Are you satisfied with your level of lubrication during sexual activity or intercourse?

Do you experience discomfort or pain during sexual activity or intercourse?

Your Safety

When you are driving or riding in a car, do you wear a seat belt?

Never

Sometimes

Most times

Always

Do you feel or have you ever felt unsafe or threatened in your home environment or relationships?

Yes

No (if you select this answer, please skip the following question)

You said that you have at some time felt unsafe or threatened:

Have you ever been in a relationship where you have you been physically harmed or threatened with physical violence?

Yes

Are your friends or family aware of this situation?

Yes

Do you have a safe place to go and the resources you need in an emergency?

Yes

Do you feel safe in all of your current relationships?

Yes

Your Overall Health & Happiness

In general, taking all things into account, how would you rate your satisfaction and happiness with your life?

Excellent

Not Good

Terrible

Nutrition
(Please include the type if you are currently taking any of the following)

Multi-vitamins

Single Vitamins (Vitamin C, E, etc)

Calcium

Herbs

Food Allergies/ Intolerances

Other

Goals & Readiness

My nutrition-related goals are:

If I could change 3 things about my health & nutritional habits, they would be:

The biggest challenge(s) to reaching my nutrition/weight loss goals are:

I have fallen in the last 6 months.

Yes

Sometimes I feel unsteady when I am walking.

Yes

I am worried about falling.

Yes

I am often dizzy when I first stand up.

Yes

I have lost some feeling or have pain in my feet.

Yes

I take medicine that sometimes makes me feel light-headed or more tired than usual.

Yes

I take medicine to help me sleep or improve my mood

Yes

I often feel sad or depressed.

Yes

. 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

Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead, or of hurting yourself

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Sleepiness Scale

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently try to work out how they would have affected you. Place an X in the corresponding space for each situation.

Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g. a theatre or a meeting)

A passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic

Thanks for submitting!

Health Assessment

About You

Your Physical Activity

Your Tobacco Usage

Your Drinking Habits

Add up the total number of alcoholic drinks you consume in an average week.

Your Eating Habits

Your Medical Health

Do you regularly have any of the following bodily symptoms?

Your Stress

Here is a list of common symptoms of depression. How much has each one bothered you during the past week, including today?

Sleep

Your Work

Your Sexual Health

FEMALES ONLY! Please answer the following questions. Thinking back over the past 6 months...

Your Safety

You said that you have at some time felt unsafe or threatened:

Your Overall Health & Happiness

Nutrition (Please include the type if you are currently taking any of the following)

Goals & Readiness

Sleepiness Scale

Nutrition
(Please include the type if you are currently taking any of the following)