LifeStyle Health Scoring
Full Name
First Name
Last Name
1. On average, how many ounces of water do you drink per day?
0-23
24-37
48-63
64+
2. Of your water intake, what % is purified via reverse osmosis or distillation?
none or little
about half
most all
every bit
3. On average, how many servings of fruit (medium piece or handful of frozen) do you eat per day?
zero
1
2
3+
4. On average, how many servings of vegetables (handful of fresh or frozen) do you eat per day?!
zero
1
2
3+
5. How often do you eat nuts, seeds, fish, or take an essential fatty acid (omega-3 or 6) supplement?!
monthly
weekly
2-6 days/wk
daily
6. On average (high & low days considered), how many servings of non-fruit/veggie starchycarbs, healthy or otherwise, (bread, rice, potatoes, oatmeal, crackers, chips, candy, soda, juice, etc) do you consume per day?
12+
8-11
4-7
0-3
7. On average, how many ounces of dairy milk do you drink per day?!
16+
9-15
1-8
none
8. How many hours of sleep do you get most nights of the week?!
0-3
4-5
6-7
8+
9. How many ounces total caffeinated beverages (coffee, soda, black tea, green tea, red bull, monster, redline, 5-hour energy, etc) do you drink most days of the week?! !
64+
32-63
17-31
0-16
10. How many ounces of total carbonated beverage do you average per week?
64+
32-63
17-31
0-16
11. How often do you consume artificially sweetened foods or drinks (aspartame, sucralose, Splenda, Sweet ‘n Low, Equal ...most sugar-free solids, liquids, & supplements) ?
daily
frequently
rarely
never
12. How many cigarettes or cigars do you smoke in an average week?!
11+
6-10
1-5
none
13. How often do you consume a multivitamin/mineral supplement?
never
sometimes
most days
daily
14. How often do you experience neck pain, back pain, or head aches?
daily
several x/wk
several x/mo
rarely
15. Do you feel that your stress response has negatively impacted your health?
definitely
probably
not sure
doubt it
16. How would you describe your typical mood?
Irritated
Depressed
Apathetic
Happy
17. How many hours do you spend outdoors in a week? (beyond walks to and from the car)
zero
about 1
about 2
3 or more
18. How many hours of deliberate exercise do you average per week?
zero
1
2
3+
% Score out of 100:
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