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LIFESTYLE ASSESSMENTThe Lifestyle Assessment Questionnaire is designed to provide insight into your personal health. Whenembarking on a personal health plan, it is important for you and your practitioner to have a benchmark ofwhere you are, your personal and family history, and what your behaviours, concerns, and thoughts are withregards to your health.The following Lifestyle Assessment Questionnaire is not designed to give a medical diagnosis. It identifiesyour current strengths, risk factors that might be present, and it highlights key areas of concern. It alsoassists in uncovering the factors that may be contributing to your symptoms or current concerns.This questionnaire will take about 1 - 2 hours to complete. The time that it takes to answer the questionsis completely up to you and has no bearing on the results.General Guidelines to Follow when filling out the Lifestyle Assessment: Use the last three months as a guide to current symptoms when answering the questions. If you feel that something that pertains to you is missing in any section feel free to add it.The Lifestyle Assessment is broken down into eight categories:A. GENERAL INFORMATIONF. PAST & PRESENT HEALTH CONCERNSB. EXTERNAL FACTORSG. REVIEW OF PHYSICAL SYSTEMSC. FAMILY MEDICAL HISTORYH. GENERAL INFORMATION ON DIETD. MEDICATIONS, SUPPLEMENTS &OTHER TREATMENTSI.PERSONAL VALUESJ.STRESSE. EXERCISEK. HEALTH POSITIONING STATEMENTSA. GENERAL INFORMATIONName:Today’s date:Date of birth:Occupation:Number in household:Relationship to you?Number of pets:What kind of pets?33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca1

A TYPICAL DAYList the amount of time you spend doing the following activities during a typical dayNote: The total time will probably add up to more than 24 hours due to the nature of the ingPersonal HygieneRelaxing or meditatingDriving a vehicleReadingTaking public transport or passengerListening to musicWorkingWatching televisionComputer related workBeing outsideHouse or yard workTime aloneSATISFACTION LEVEL ON DIFFERENT ASPECTS OF YOUR LIFEUsing the scale provided identify your level of satisfaction with respect to the categories listed.Scale: 1 - not comfortable at all with current situation2 - low level of comfort with current situation3 - okay most of the time with current situation4 - fairly comfortable with current situation5 - high level of comfort with the current situationCategorySatisfaction or Comfort Levelwith the SituationChanged inLast 3 MonthsChanged inLast ESNOYESNORELATIONSHIPS12345YESNOYESNO33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca2

B. EXTERNAL FACTORSThe following section identifies external and environmental factors that may be affecting your health. Pleasecheck the box that is the most appropriate, or fill in the blanks as indicated.ENVIRONMENTWhere did you grow up?Where do you live?Type of home? citysuburbs apartment/condo country semi/townhouse farmdetached houseDo you live near hydro towers? YES NO In the pastNumber of years?Do you live near a factory? YES NO In the pastNumber of years?Please list any chemicals, toxins, or other factors in your environment that might be affecting your health:PERSONALWhat are your hobbies?How much time do you spend in nature?Do you smoke? YES NO Does anyone in your family smoke? In the pastYESDo you use natural personal care products? How many packs a day?NOYES In the pastNOIf so, what brand?Do you pay attention to the chemicals in personal care products? YES NODo you use sunscreen? YES NOIf so, what brand?Do you dye your hair? YES NOIf so, what type? YES Do you have any body piercings?NOHow often?If so, where?Do you have any permanent tattoos? YES NOHave you had any cosmetic surgery? YES NOIf so, when?What type of cosmetic surgery?How many hours a day do you spend watching television?Do you use wireless networks What type of phones do you use?at home? at work?cord cordless On a computer?If so, how many hours daily? cellularHow many hours a day are you on a cell-phone or PDA?Do you wear an ear piece for your phone?33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7NOIf so, how many hours daily?Telephone: 905-940-2727Fax: uropathicfoundations.ca YES 3

What types of Bluetooth devices do you use?How many trips on an airplane do you take a year?HOUSEHOLDType of house you grew up in?Number of times you have moved homes?Have there been any recent home renovations? Is there a history of flooding in your home? YES YES NODo you use natural cleaning products? YESHow old is your current home?NO NOIf so, what type? In the pastIf so, what brand/type?What type of cooking utensils (pots and pans) do you use?What type of storage containers do you use?What type of container do you use to carry your drinking water?WORKDo you enjoy your work? YES NOWhy?Describe your work load:On average how many hours do you work a day?Do you bring your work home with you?How active is your work day? sedentaryYES activeNOHow many hours a week?If so, why?Please describe:How would you describe the dynamics at work?Are there any other external or environmental factors that you feel may be affecting your health?33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca4

C. FAMILY MEDICAL HISTORYPlease indicate which family relatives (mother, father, grandparents, siblings, aunts or uncles) have everencountered the following health concerns:Health ConcernAlcoholismAllergiesAlzheimer's diseaseArthritisAsthmaCancer (indicate type)DiabetesDrug addictionEating disorderGenetic disorderGlaucomaHeart diseaseFamily Relative# of siblingsHealth ConcernHypertensionInfertilityIntestinal diseaseLearning disabilityMental illnessMigraine headachesNeurological ly RelativeYour birth orderD. MEDICATIONS / SUPPLEMENTS AND OTHER TREATMENTSPlease check any of the following medications that you are taking or have taken in the last 2 years:antacids chemotherapy radiation appetite suppressants diuretics (water pills) recreational drugs aspirin / tylenol laxatives sleeping pillsbirth control pills pain relievers tranquilizers Any known allergies or drug sensitivities?Number of times on antibiotics in the last 10 years?Number of times on corticosteroids in the last 10 years oral?topical?DRUGS (if more space is needed, please attach a separate sheet)Listing of Drugs33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Dosage / AmountReason for TakingTelephone: 905-940-2727Fax: 905-940-2721Duration of foundations.ca5

VITAMINS, SUPPLEMENTS, HERBAL OR HOMEOPATHIC REMEDIES(if more space is needed, please attach a separate sheet)Listing of MedicationsDosage / AmountReason for TakingDuration of UseOTHER TREATMENTSPlease comment on other natural / alternative treatments that you have used.TreatmentsPastAcupuncture / Chinese MedicineAromatherapyArt TherapyAyurvedic MedicineBiofeedbackChiropracticColonicsCranial Sacral TherapyEnergetic TherapiesHerbal ogyMagnetic TherapyMassage TherapyMusic TherapyNaturopathic MedicineOsteopathyPhysiotherapyPolarity TherapyReflexologyReikiShiatsuOther33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7CurrentComments / EffectivenessTelephone: 905-940-2727Fax: uropathicfoundations.ca6

E. EXERCISEUsing the scale provided, identify the number of times a week that you engage in the following exercises.Scale: a (never), b (seldom or less than once per week), c (1 - 3 times per week), d (3 - 5 times per week),e (often or more than 5 times per week).Never 1/wk1-3/wk3-5/wk 5/wkBODY / MIND EXERCISESMeditation / Prayer / Breathing ExercisesVisualizations (or similar)OtheraaabbbcccdddeeeSTRENGTH BUILDINGWeight TrainingMartial Arts (or similar)OtheraaabbbcccdddeeeCARDIOVASCULAR EXERCISESHigh Impact Aerobics / StepRunning / JoggingLow Impact Aerobics / WalkingCycling / Rowing / SwimmingOtheraaaaabbbbbcccccdddddeeeeeFLEXIBILITY EXERCISESYoga / Tai Chi / Qi Gong (or similar)General Stretching / LengtheningOtheraaabbbcccdddeeeHow active is your day?On average, how many hours do you exercise per week?Do you belong to a gym? YESDo you prefer to exercise alone? NO withIf so, how often do you go?others? aspart of a class?What benefits have you found from exercising?Choose the statement that describes you best: I exercise because I have to (someone has advised an exercise program) I exercise because I want to exercise for my own health and wellness. I exercise because I enjoy exercising.33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca7

F. PAST AND PRESENT HEALTH CONCERNSDid you have any health problems at birth?How was your health as a child?Describe your health during puberty / teenage years:Please list any injuries, hospitalizations, accidents or medical procedures that you have had:(if required, attach a separate sheet)EventWhen?Treatments?Have you been diagnosed with any illnesses? ExplainWhat are your current health concerns?When did you notice any changes to your health?What have been the most traumatic events in your life?33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca8

G. REVIEW OF PHYSICAL SYMPTOMSENERGY LEVELOn a scale of 1 (low) to 10 (high) rate your energy level?What time of the day is your energy the highest?What time of the day is your energy the lowest?What affects your energy?SLEEPHow is your sleep?Do you ever suffer from insomnia?How often?How many hours a day do you sleep?Do you nap?Are you a restful and sound sleeper? If not, please explain.Do you wake feeling rested?Do you have frequent dreams and nightmares?BREATHINGHow would you describe your breathing?Do you have shortness of breath on exertion?What affects your breathing?BODY TEMPERATUREWhat is your normal body temperature?Do you like to be warm or cool?Do you become overly hot or cold throughout the day?WEATHERAre you affected by the weather?What is favourite type of weather?What is your least favourite type of weather?33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca9

GENERAL SIGNS andSYMPTOMSCurrentIntensityPastConcern?1 2 3 4lowhighLengthof TimeComments(years)feverrapid weight lossrapid weight gainoverweightunderweightsensitive to noisesensitive to lightsensitive to odoursother sensitivitiesHeight? inches centimetresWeight?What do you think would be an acceptable body weight for you?PastConcern?HEAD and MOUTHCurrentIntensity1 2 3 4lowhighLengthof Time lbslbs inesfrequent sore throatshoarsenessdry mouthsore tongue/mouthcold sores/herpesgum problemsbad breathswollen glandslumps/goitrenose bleedsloss of smellother concernsNumber of dental cavities?Last dental check up?Do you floss?Have you had any extensive dental work? cosmetic dentistry 33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7oral surgeryNumber of amalgams (silver fillings)? YES NOorthodonticsDo you brush regularly?If so, please indicate: Telephone: 905-940-2727Fax: 905-940-2721periodontal therapy icfoundations.ca10

EYES and EARSCurrentIntensityPastConcern?1 2 3 4lowhighLengthof TimeComments(years)near sightedfar sightedblurred visiondry eyestearingitchy eyeseye painredness in eyeseye dischargedark circles under eyesbothered by the suneye infectionsglaucoma/cataractsdiminished hearingear achesear infectionsringing in ears (tinnitus)other eye/ear concernsDate of last eye exam?RESPIRATORYSYSTEMAny eye procedures?CurrentIntensityPastConcern?1 2 3 4lowhighLengthof TimeAny hearing aids?Comments(years)coughsputum/mucoussinus congestionspitting up bloodwheezingshortness of breathdifficulty culosisotherDate of last chest x-ray?33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca11