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Lifestyle Questionnaire
These questions will give me a better understanding of who you are, leading to a deeper therapeutic relationship and allow us to reach our shared goals. Please do not feel pressured to answer any of the questions and it is totally fine if you would rather not share.
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* Indicates required question
Email
*
Your email
Name and Age
*
Your answer
What is your marital status?
Married
Divorced
Separated
Single
How many children do you have?
Your answer
What are your main health concerns?
Your answer
Which of the following are you doing for your health at the moment?
Exercise
Improving diet and nutrition
Chiropractic care
Regular lab work
Vitamins
Minerals
Herbs
Prescription Medications
Relaxation Techniques
Acupuncture
Meditation
Physical Therapy
Other:
What do you beleive might be the causes or underlying factors of your current health concerns?
Your answer
Have you expereinced trauma or loss in the past? If so, please provide a brief description if you are comfortable doing so. It is okay to leave this blank if you do not feel comfortable sharing.
Your answer
What level of stress are you experiencing during this time in your life?
Minimal
Average
Considerable
Unbearable
Clear selection
What are the major causes of stress in your life?
Financial
Career
Personal
Marriage
Relationships
Mental Health
Physical Health
Family
Spiritual
Unfulfilled Expectations
Other:
How does your stress manifest in your life? For example, increased pain, headaches, difficulty sleeping, increased fighting with family and friends, ect.
Your answer
Do you utilize any coping mechanisms for your stress?
Option 1
Clear selection
How many hours do you sleep daily on average?
Your answer
On average, what time do you go to sleep?
Your answer
On average, What time do you wake up?
Your answer
Do you wake up feeling rested?
Yes
No
Sometimes
Clear selection
Are you satisfied with your energy levels? If not, how long have you felt like your energy levels have been lower then you would like.
Your answer
What is, or was your occupation?
Your answer
How many hours do you work each day?
Your answer
Do you enjoy your work?
Yes
No
Sometimes
Clear selection
Do you smoke cigarettes regularly?
Yes
No
Socially
Clear selection
If you do smoke cigarettes, how many do you smoke on average each day?
Your answer
How many hours do you spend daily, on average...
0-1 hours
1-2 hours
2-3 hours
3-4 hours
4-5 hours
5-6 hours
6-7 hours
Column 8
Driving
Watching TV
Reading
On Social Media
Using Your Computer
Walking
Doing hobbies or activities that you love
0-1 hours
1-2 hours
2-3 hours
3-4 hours
4-5 hours
5-6 hours
6-7 hours
Column 8
Driving
Watching TV
Reading
On Social Media
Using Your Computer
Walking
Doing hobbies or activities that you love
Do you exercise? If so, what do you typically do?
Your answer
How frequently do you exercise?
Your answer
What are your interests and hobbies?
Your answer
Do you take vacations regularly?
Your answer
When was your last vacation?
Your answer
Do you participate in church or other spiritual activities?
Yes
No
Clear selection
How tall are you?
Your answer
How much do you weigh?
Your answer
Do you wish to gain or lose weight?
Yes
No
Clear selection
How much weight would you like to gain or lose?
Your answer
On average, How many times per day do you eat?
Your answer
Do you snack throughout the day?
Option 1
Yes
No
Clear selection
On average, Do you eat meals...
with family
Alone
At home
In a restaurant
On the run
Fast Food
At what time do you have your last meal or snack of the day?
Option 1
Clear selection
Do you eat or use any of the following products?
Aluminum pans for cooking
Margarine
Candy
Canola oil/Corn oil/Soy oil/Sunflower oil/cottonseed oil
Cigarettes
Artificial Sweeteners
Fast Foods
Air Fresheners
Please indicate how many cups of the following you drink per day.
0 cups
1 cup
2 cups
3+ cups
Water
Coffee
Caffeinated Tea
Fruit Juice
Vegetable Juice
Animal Milk
Soft Drinks
Beer
Wine
Liquor
Row 11
0 cups
1 cup
2 cups
3+ cups
Water
Coffee
Caffeinated Tea
Fruit Juice
Vegetable Juice
Animal Milk
Soft Drinks
Beer
Wine
Liquor
Row 11
Clear selection
Are you a...
Meat-eater
Vegan
Vegetarian
Pescatarian
Other:
Clear selection
How often do you eat meat?
Your answer
How often do you consume dairy products?
Your answer
What are your favorite foods?
Your answer
Do you experience any symptoms if you miss a meal? If so, what?
Your answer
Do you experience any symptoms after eating? If so, please describe.
Your answer
Are there any foods that you avoid? If yes, why?
Your answer
What are the goals you aspire to achieve for the next 12 months?
*
Your answer
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