LIFESTYLE ASSESSMENT - Naturopathic Foundations


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: 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

SKINPastConcern?CurrentIntensity1 2 3 4lowhighLengthof TimeComments(years)dry/cracked skinmoist/oily skinrasheseczemapsoriasisdry scalp/dandruffhair thinning/lossacne/boilsitchingcolour changespale complexionchanges in moleswartslumps/cystsstretch marksexcess body odourexcessive sweatingjaundiceskin cancerother skin concernsNERVOUS SYSTEMPastConcern?CurrentIntensity1 2 3 4lowhighLengthof TimeComments(years)faintingloss of ionspeech problemsmemory problemsseizures/convulsionsparalysisother33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca12

VASCULAR SYSTEMPastConcern?CurrentIntensity1 2 3 4lowhighLengthof TimeComments(years)hot hands/feetcold hands/feetdeep leg painleg crampshigh blood pressurelow blood pressurechest painslow heart beatfast heart beatpalpitationscyanosis (blue skin)extremity swellingextremity numbnessvaricose veinseasy bleeding/bruisingextremity ulcersanaemiaheart murmursotherHave you ever had a heart stress test?MUSCLES and BONESPastConcern?CurrentIntensity1 2 3 4lowhighLengthof TimeComments(years)broken bonespainful jointsswollen jointslack of joint mobilitymuscle strain/sprainmuscle spasmsprolonged stiffnessheavy feeling in limbsmuscle weaknessmuscle atrophy(deterioration)low back painweak/sore kneesarthritis33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca13

Have you had any falls or injuries? YES NOIf yes, describe:How would you describe your posture?Is there anything that affects your posture on an ongoing basis?How would you describe your flexibility?Do you have issues with the range of motion of any of your joints? YES NOIf yes, describe:Date of last bone scan?Results?Please mark an ‘x’ to indicate areas where you feel pain, swelling or discomfort.33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca14

DIGESTIVE SYSTEMPastConcern?CurrentIntensityLengthof Time1 2 3 4lowhighComments(years)change in appetitechange in thirstchange in tastetrouble swallowingbitter tastenauseavomitinggas or belchingabdominal rrheahemorrhoidsundigested food in stoolblood in stoolotherBOWEL MOVEMENTSOn average how many bowel movements do you have a day?Do you strain to have a bowel movement?What colour are your stools?Describe the consistency / size of your bowel movements?APPETITEDescribe your appetite:Describe your digestion:What makes your digestion worse?What happens if you skip a meal?What type of foods do you prefer? salty sweet spicy bitter sourWhat temperature of food do you prefer?Any food allergies or intolerances?33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca15

THIRSTDescribe your thirst:What temperature of drinks do you prefer?What do you prefer to drink?How much water do you drink in a day?What type of water you drink?URINARY SYSTEMPastConcern?CurrentIntensity1 2 3 4lowhighLengthof TimeComments(years)urinary pain/burningdifficult urinationincreased frequencyurgency/inability tohold urinefrequent infectionsblood in urinekidney stonesotherNumber of times a day you urinate?Is there any odour to your urine?MALEREPRODUCTIVESYSTEM PastConcern?YESNumber of times you get up at night to urinate? NOCurrentIntensity1 2 3 4lowhighIf yes, please describeLengthof TimeComments(years)herniastesticular massestesticular painsexual difficultiespremature ejaculationdischarge or soresprostatitisvenereal diseaseAre you currently sexually active? YES NOSexual preference?What is your sexual desire (rate on a scale of 1 (low) to 10 (high))?33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca16

n?Lengthof Time1 2 3 4lowhighComments(years)bleeding between periodsdischarge between periodspain during intercoursePMSbreast discomfort/changesfluid retentionhot flashesnight sweatsfrequent fungal/yeast infectionsAge menses began:Days flow lasts:Describe your flow:Days between periods:When is it the heaviest?What is the flow like (clots, colour)?What symptoms are associated with your period?Any pain with your menses? YESAre you practising birth control? If so, when is it the worse?NOIf so, what type and since when?Number of pregnancies:Number of live births:Number of miscarriages:Number of abortions:Any problems conceiving? YESNOYES NOIf yes, explain:Have you done any fertility treatments? YES NOIf yes, explain:Are you currently sexually active? YES NOSexual preference?What is your sexual desire (rate on a scale of 1 (low) to 10 (high))?Have you ever been diagnosed with a venereal disease? YES NOIf yes, what type?Date of last PAP?Last menstrual period?Any menopausal symptoms?If yes, describe: YES NO33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca17

Concern?1 2 3 4lowhighLengthof TimeComments(years)no free timemood swingsoverly emotionalfears/phobiasdepressedinability to let things gojealousycry sanxietyanxiety about exams/public speakingburnoutfeeling out of controllack of concentrationlearning disabilityDo you have an active mind? YES NODescribe your mind chatter:What kinds of tools have been helpful to you on a mental/emotional level?Do you have a support network? YES NOPlease elaborate:33 The Bridle Trail, Unit 3Markham, Ontario L3R 4E7Telephone: 905-940-2727Fax: uropathicfoundations.ca18

H. GENERAL INFORMATION ON DIETOn a scale of 1 - 10 (low - high) how would you rate your diet?Why?Is there anything about your diet you would like to change?On average how many meals do you eat a day? 1 23 Breakfast 4 5Lunch 5DinnerHow much time do your spend preparing?How much time you spend eating?Are there any foods that you crave?Do you follow any specific diet regime?Do you usually eat alone? vegetarian Avoid?vegan with others?Do you pay attention to the quality of the food that you eat? YESAre you aware of any differences in how you feel with different foods?What percentage of your diet is proteins?vegetables?Do you monitor your intake offat? Do you add SALT to most meals? Do you eat according to the season?Do you enjoy food? YESDo you enjoy preparing food?other YES NO YESsalt? YES Do you look forward to meal time / eating? NOYES NOcarbohydrates?fruit?other?fibre? sugar?NO NONO YES NOWhich statement describes you best? I look for quick, convenient food choices when grocery shopping and making meals. I like to eat natural, whole and fresh food whenever I can. Someone else is usually responsible for what I eat. I eat out whenever I can.33 The Bridle Trail, Uni

The Lifestyle Assessment Questionnaire is designed to provide insight into your personal health. When embarking on a personal health plan, it is important for you and your practitioner to have a benchmark of where you are, your personal and family history, and what your behaviours, concerns, and thoughts are File Size: 512KB