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Surveys
2013
July
L
Lifestyle Assessment Questionnaire
Lifestyle Assessment Questionnaire
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Questions marked with an
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Contact Information
*
First Name
:
*
Last Name
:
Address 1
:
Address 2
:
City
:
Province
:
Postal
:
Phone
:
*
Email Address
:
Body Details:
Age
Sex
Height
Weight
What is your purpose in coming here today?
What are your main health concerns/complaints? Please list in priority:
Have you experienced any major trauma in the past 5 years? Please describe:
What level of stress are you experiencing at this time? Please rate from 1 (low) to 10 (high):
Overall Stress Level:
-- Select --
1
Please rate the major causes or factors of your stress from 1 (low) to 10 (high):
Financial
-- Select --
1
2
3
4
5
6
7
8
9
Career
-- Select --
1
2
3
4
5
6
7
8
9
Personal
-- Select --
1
2
3
4
5
6
7
8
9
Marriage
-- Select --
1
2
3
4
5
6
7
8
9
Health
-- Select --
1
2
3
4
5
6
7
8
9
Family
-- Select --
1
2
3
4
5
6
7
8
9
Spiritual
-- Select --
1
2
3
4
5
6
7
8
9
Unfulfilled Expectations
-- Select --
1
2
3
4
5
6
7
8
9
Other (see next question to elaborate)
-- Select --
1
2
3
4
5
6
7
8
9
Please Elaborate "Other" from previous question, if applicable:
How does your stress manifest itself?
Do you use coping mechanisms for stress? If so, please describe:
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