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DREAM Score Questionnaire
1
Name
*
This field is required.
First Name
Last Name
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2
Email Promise
I am providing my email to receive the report, and I give permission to have information and promotions sent to me regarding my overall health and lifestyle. I am aware that I can opt out of future emails at any time.
I am providing my email only to receive a copy of my report, and for information related to the DREAM Score. I am aware that I can opt out of future emails at any time
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3
Email
*
This field is required.
example@example.com
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4
Age (optional)
Don't worry, we won't tell anyone!
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5
Where in the world do you reside? Be as specific as comfortable. (Optional)
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6
How did you learn about the DREAM Score?
Referral Source
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7
Today's Date
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Date
Month
Day
Year
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8
Were you referred to the DREAM Score by one of our Valued Implementation Partners (VIP) that you would like to have your report and results sent to? (If you are unsure, choose NO)
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YES
NO
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9
Do you know your provider's VIP number?
*
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By choosing YES, you are giving DREAM Wellness permission to send your responses, results and report to your provider. You will sign the HIPAA Release at the end of the assessment.
YES
NO
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10
Type your provider's 5 digit VIP number:
*
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If this shows up on your form by mistake, just type any number and click NEXT.
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11
What is the full name of your provider?
*
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We will do our best to locate your provider's VIP number and send the results. This may cause a slight delay in them receiving the results.
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12
I consume vegetables...
*
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Never
Rarely, maybe one serving per week or less
Sometimes, between two and three servings per week
Daily, at least one serving per day
Daily, I have vegetables with at least 2 meals per day or throughout my day
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13
Consume Veggies Suggestion
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14
Empty
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15
When I eat fruit and vegetables, they are organic
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I don't eat fruit and vegetables
I eat fruit and vegetables, but I do not know if they are organic (or less than 20%)
Approximately 20-60% of my fruit and vegetables are organic
Approximately 60-90% of my fruit and vegetables are organic
More than 90% of my fruit and vegetables are organic
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16
Organic suggestion
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17
I am conscious of my caloric intake, as well as macro-nutrient (protein, carbohydrate, fat) and micro-nutrient (vitamin/mineral) consumption, AND keep them in appropriate proportions.
*
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(This does not mean "counting calories" but more about being mindful.)
I eat what I want, when I want it and don't care enough to keep track
I am somewhat conscious but it doesn't affect how I eat
I keep my macro-nutrients and micro-nutrients in appropriate proportions most of the time
I am very aware and work daily to maintain appropriate proportions
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18
Calorie Suggestion
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19
I avoid food items that are made with refined flour, refined sugar, hydrogenated oil, artificial food coloring and high fructose corn syrup.
*
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What the heck is refined? And corn syrup... yum!
I would like to think I do, but in reality, not so much
I do my best to avoid them, but I don't try that hard
I avoid them as much as I can, but cheat from time to time
I won't touch any of those items
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20
Corn syrup suggestion
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21
I typically skip breakfast...
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Never
1 to 3 times per week
4 to 6 times per week
I don't eat breakfast
My breakfast is a cup of coffee
This question is not applicable when I practice intermittent fasting
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22
Breakfast
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23
The amount of pure water I typically drink daily is... (beverages that contain water are not included)
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This is your typical day, not taking into account with/following excessive exercise or very hot days
I don't drink water
A sip here and there
Probably a couple of glasses but I don't keep track
Around 2-5 glasses per day (each glass is 8 ounces or just under 1/4 of a liter)
6 or more glasses per day (at least 64 ounces, just under 2 liters)
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24
Water Suggestion
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25
I typically eat processed snack food (chips, cookies, crackers, puffs, popcorn, etc…)
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Typically, one or more per day
A few snacks per week
Pretty often, but ONLY higher quality that is either Organic or Non-GMO
I will have snack food on occasion, but ONLY higher quality that is either Organic or Non-GMO
Very rarely or never
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26
Processed Suggestion
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27
I eat at fast food restaurants...
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This is not referring to "fast" cafeteria style places such as Whole Foods, but the more typical fast food establishment such as McDonald's, Burger King, Taco Bell, KFC, Jack in the Box, etc...
Frequently- more than 3 meals per week
Occasionally- approximately 1 meal per week
Rarely- maybe 2 meals per month
Very rarely- maybe 1 meal every 3 months
Never- I wouldn't be caught dead in a fast food establishment unless it was an extreme circumstance (like a road-trip and there were no other options)
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28
Fast food
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29
I eat dessert made with sugar after my dinner (other than fresh fruit)...
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All of the time
Most of the time
Some of the time
Not typically, unless it is a celebration
Very rarely / never
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30
Sugar
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31
I smoke cigarettes, Vape or chew tobacco...
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All the time
At least once per day
A couple of times per week
Rarely- once per month or less
Never
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32
Tobacco
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33
I typically consume beverages containing alcohol...
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Scroll down for all choices if using a mobile device
Daily: 1 drink per day (equivalent to 1 glass of wine)
Daily: 2 drinks per day
Daily: 3 or more drinks per day
Weekly: 1 drink per week or less (but more than 1 per month)
Weekly: 2 drinks per week
Weekly: 3 or more drinks per week
I drink one time per week or less, but when I do drink, it's usually 5 or more drinks at that time
Monthly: Maybe 1-3 drinks per month
Less than 1 drink per month
Never, I don't drink alcohol
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34
Alcohol
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35
Outside of work or education, how much time do typically spend on screens daily (social media, games, videos, tv, etc)?
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More than 4 hours
Between 2 - 4 hours
Between 1-2 hours
Very little, less than 1 hour
Never
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36
Screen time
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37
I consume coffee (not-decaffeinated) and/or other caffeinated beverages...
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More than once per day
Once per day
1-5 times per week
A couple of times per month
Less than once per month / rare occasions / never
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38
Caffeine
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39
Prior to eating any meal, I consciously think about whether it is good for me or not.
*
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It doesn't mean that you will or won't eat it, it's just to determine how conscious you are about the quality of the food you consume
No, that's not me
Rarely
Sometimes
Frequently
Always
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40
Conscious Consumption
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41
My cookware at home has non-stick surfaces such as Teflon (as opposed to being naturally non-stick because of a high quality titanium stainless steel)
*
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I don't know
Yes
No
Some does and some doesn't
I don't use cookware at home, only a microwave
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42
Cookware
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43
The percentage of meals that I consume in a typical week that are prepared at home would be:
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None, I always eat out
10% - 20%
21% - 50%
50% - 80%
More than 80%
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44
Meals at home
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45
In a typical meal prepared at home, how many items are from a can?
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I don't know, or I don't eat home cooked meals
More than one item comes from a can
One item comes from a can
I very rarely prepare foods at home that include ingredients from a can
Never; I don't purchase canned items
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46
Cans
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47
My food and beverages contain artificial sweeteners such as Aspartame, Sucralose and Saccharin found in Equal, Splenda, NutraSweet, Sweet 'n Low (Think of diet soda, coffee/tea sweeteners, protein powders, etc...)
*
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We are not including Stevia and sugar alcohols such as Xylitol, Erythritol, Sorbitol and Maltitol
I have no idea
At least one food/beverage item daily
At least one food/beverage item approximately 3 times per week
At least one food/beverage item 1 to 2 times per month, but I do my best to avoid them
Extremely rare or never
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48
Artificial Sweetener
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49
I typically drink carbonated beverages such as soda and/or energy drinks (diet or not)
*
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Not including tonic, club soda or soda water
Never
Rarely
Occasionally (maybe once or twice per week)
Frequently (between 3 times each week to every day)
More than once most days
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50
Soda
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51
I take any or all of the following supplements (or similar): Multi-vitamin, Vitamin D3, Vitamin C, fish oil, anti-oxidants, greens, probiotics
*
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Never
Not typically
When I remember
Daily
Rarely or never, but I am extremely conscious about my food intake and I do everything possible to ensure that my daily diet is rich in omega-3 and omega-6 fatty acids, anti-oxidants, greens, probiotics, etc...)
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52
Supplements
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53
Diet Points
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54
I get enough sleep to wake up well rested...
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Always
Usually
Not frequently enough
Never
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55
Sleep
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56
I take time for meditation and/or quiet prayer throughout my week...
*
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Disagree
Some weeks I do, some I don't
Agree
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57
Meditation
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58
I consume foods and beverages with sugar (including fruit juices) and/or caffeine...
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Very rarely or never
Sometimes- maybe once or twice per week at most
Multiple times per week
Daily
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59
sugar and caffeine
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60
My bed is very comfortable...
*
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Strongly disagree!
Disagree
It's fine I guess, it's a bed
Agree
Strongly agree, I love my bed!
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61
Mattress
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62
My pillow is the right size for me and very comfortable...
*
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Strongly disagree!
Disagree
It's fine I guess, it's a pillow
Agree
Strongly agree, I love my pillow!
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63
Pillows
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64
I consider myself to be organized...
*
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Strongly disagree
Disagree
Neutral
Agree
Strongly agree
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65
Organized
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66
I make time to take care of myself...
*
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Strongly disagree
Disagree
Neutral
Agree
Strongly agree
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67
I prioritize the important tasks in my life...
*
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Strongly disagree
Disagree
Neutral
Agree
Strongly agree
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68
I have so much to do that I'm often overwhelmed...
*
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Strongly disagree
Disagree
Sometimes
Agree
Strongly agree
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69
Overwhelm
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70
I recite daily affirmations and/or prayers...
*
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Strongly disagree
Disagree
Sometimes
Agree
Strongly agree
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71
Affirmations
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72
I am able to remain calm, even in busy or challenging situations...
*
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Strongly disagree
Disagree
It depends... sometimes yes, sometimes no
Agree
Strongly agree
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73
The last thing I do before going to sleep is calming, relaxing and peaceful...
*
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Strongly disagree
Disagree
It depends... sometimes yes, sometimes no
Agree
Strongly agree
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74
Calm night
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75
I am not afraid to put myself first (not in a selfish way)...
*
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Strongly disagree
Disagree
Sometimes
Agree
Strongly agree
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76
I do yoga and/or breathing exercises...
*
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Never
Once every few months
1-4 times per month
1-3 times per week
4-7 times per week
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77
Yoga
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78
When I get invited to do an activity (that I enjoy) with friends/family, typically...
*
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I have to say no because I don't have the time
I say yes, but I am often stressed because I have so many other things I need to do
I say yes and I am very excited about it
I say yes, but often need to cancel last minute because something else comes up
It really depends... I typically have a busy schedule, but when I can participate, I do
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79
Invitations
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80
I am at total peace with my current financial situation...
*
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Always
Most of the time
Sometimes
Rarely
Never
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81
My living situation allows for peace and tranquility.
*
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Never
Rarely
Sometimes
Most of the time
Always
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82
Under normal circumstances, my daily commute is typically...
*
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This is not taking into account a
rare
traffic jam
Very stressful
A little stressful
Enjoyable
Neutral
I don't have a commute
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83
I participate in a creative outlet that enables self-expression, tranquility and reflection such as journaling, music, art, crafts, etc...
*
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Frequently
Sometimes
Rarely
Never
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84
Creativity
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85
My living situation is...
*
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Hectic, busy and erratic; anything but tranquil
Filled with drama
Busy but manageable
Mostly tranquil
Extremely tranquil
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86
Relaxation Points
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87
I do some type of cardiovascular (aerobic) activity or exercise...
*
This field is required.
Activities may include running, jogging, fast-paced (brisk) walks, biking, stair climbing, elliptical, aerobics class, step class, circuit training, HIIT, etc…)
Never or very rarely
Once per week
2 times per week
3-4 times per week
More than 5 times per week
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88
Cardio
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89
I do strength training exercises (anaerobic) for at least 20 minutes duration...
*
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Activities may include weight lifting, plyometrics, isometrics, circuit training, etc...
Never or very rarely
Once per week
2 times per week
3-4 times per week
More than 5 times per week
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90
Strength
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91
I exercise and eat food in appropriate proportions based on my body type...
*
This field is required.
This is referring to ectomorph, endomorph and mesomorph
I don't do any exercise
I have no idea what my body type is and I feel I should be getting better results from my what I do
I have no idea what my body type is, but whatever I am currently doing is working well
Yes, I know my body type and I exercise and eat accordingly
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92
Body Type
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93
I am an active person...
*
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Strongly disagree
Disagree
Sometimes
Agree
Strongly agree
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94
Active Person
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95
I stretch my body...
*
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Never ever, no matter what
Only when I'm hurting and feel I need to stretch
Once per week
Multiple times per week
Daily
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96
Stretch
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97
I choose to take the stairs rather than the elevator or escalator when reasonable (approximately 4 flights or fewer)...
*
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Strongly disagree; if there's an elevator or escalator, I'm taking it!
Disagree; I would usually take the elevator or escalator
Agree; I would usually take the stairs if they are close and I'm in the position to do so
Strongly agree; I will almost always walk the stairs when I have the opportunity
This question is not applicable to me due to physical constraints, but I would if I could
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98
Stairs
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99
I participate in recreational activities such as exercising, skiing, snowboarding, rock climbing, dancing, hiking, golf, tennis, racquetball, football, basketball, soccer, baseball, softball, etc…)
*
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Never or very rarely
Maybe once per month
Between two and four times per month
Once per week
Multiple times per week
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100
When exercising, I monitor my heart rate to ensure that I am working within my target zone...
*
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I don't exercise
Disagree, but at least I'm exercising!
Agree, I do it during some exercises (usually when it's on the machine)
Strongly agree, pretty much all of the time
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101
Heart rate
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102
If I were dropped off by a spaceship on a planet that has gravity, I would be able to find a way to stay in shape
*
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Strongly disagree
Disagree
Agree
Strongly agree
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103
I participate in activities that stimulate my mind and keep me thinking...
*
This field is required.
This may include crossword puzzles, jigsaw puzzles, board games, trivia, reading articles or non-fiction, etc...
Daily
Multiple times per week
Once per week
Multiple times per month
Rarely or never (less than once per month)
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104
Stimulate mind
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105
Exercise Total
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106
I strive to maintain balance in every aspect of my life...
*
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Absolutely Disagree
Disagree
Neither Agree or Disagree
Agree
Absolutely Agree
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107
I am conscious of how I carry myself (posture)
*
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Absolutely Disagree
Disagree
Neither Agree or Disagree
Agree
Absolutely Agree
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108
Posture
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109
When I have a "trauma" to my body, I seek care to fix a resulting issue rather than just letting it go or treating the symptom.
*
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Absolutely Disagree
Disagree
Neither Agree or Disagree
Agree
Absolutely Agree
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110
When lifting heavy objects, I am conscious of my body and lift properly (bend at the knees, etc…)
*
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Absolutely Disagree
Disagree
Neither Agree or Disagree
Agree
Absolutely Agree
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111
Lifting
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112
When I exercise, I maintain optimal form throughout each activity.
*
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I don't exercise
Disagree
Neither Agree or Disagree
Agree
Absolutely Agree
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113
I wear footwear that supports a natural stride.
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Rarely/Never
Sometimes. It depends on what I'm doing.
Neither Agree or Disagree
More often than not
Always
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114
Orthotics
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115
I have my spinal alignment evaluated by an appropriately licensed healthcare provider at least twice per year to evaluate for optimal structure and function; and to ensure I am expressing optimal communication between my brain and my body (regardless of how I feel).
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Absolutely disagree
Disagree, but I have been evaluated in the past
Only when I have a pain or symptom
Absolutely Agree
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116
Spinal Alignment
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117
I get routine bodywork (including massage), exercise regularly, eat healthy foods, maintain a positive attitude and stay well rested.
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Absolutely Disagree
Disagree
Neither Agree or Disagree
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118
I strive to limit chemical stressors in my life (drugs/medications, artificial sweeteners, caffeine, non-organic foods, toxic ingredients in personal care & household cleaning products)
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Absolutely Disagree
Disagree
Neither Agree or Disagree
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119
Chemical Stressors
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120
I strive to limit emotional stressors in my life (drama, people with drama, "toxic" family or friends)
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121
Emotional Stressors
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122
Adjustment Total
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123
I participate in healthy relationships and a rich social network of friends and activities.
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124
Friends
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125
I choose activities that enable me to smile and laugh a lot.
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126
smile and laugh
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127
I enjoy what I do daily...
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128
Enjoy daily life
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129
I have a sense of purpose and I live my life to fulfill it.
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130
Purpose
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131
I maintain an attitude of gratitude.
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132
Gratitude
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133
I choose to handle all setbacks gracefully.
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134
Graceful Setbacks
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135
I choose to relate well with people I see on a daily basis (including co-workers if applicable)
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136
I set goals, take action to accomplish them and monitor my progress.
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137
Goals
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138
I am regularly exposed to social media and/or news that impacts my mood negatively
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139
Social media
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140
I learn new things every day.
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141
Learn new things
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142
I practice some form of spirituality / religion / faith.
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143
Prayer
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144
I allow my life to be filled with "toxic" people, thoughts, words, news, etc...
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145
Toxic thoughts...
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146
My life is filled with "drama".
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147
Drama
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148
I find myself gossiping about others with my friends, family or co-workers.
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149
Gossip
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150
I get a sense of guilt when I consume food that I know is not very healthy.
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Disagree, doesn't affect me at all
Agree, I feel a little guilty
Strongly agree, I feel very guilty
Not applicable to me because I always eat healthy food
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151
I choose to watch television and movies that are uplifting and/or educational (as opposed to being filled with violence, heavy drama, divisive rhetoric, bad language or sexually explicit material).
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Disagree
Sometimes... I watch a mix of different types of programs
Agree... between 60-90% of the time
Strongly agree... more than 90% of the time
I don't watch TV or go to the movies
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152
Media
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153
I love myself and I would have no problem looking into a mirror and saying out loud, "I love you!".
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Disagree
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154
Self-love
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155
I choose to be "inner directed" (not allow outside influences affect my mood).
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Strongly Disagree
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156
Inner directed
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157
I get bummed or feel like I'm depriving myself when I pass on an opportunity to eat something that is not healthy for me.
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Strongly Disagree, if anything, I feel empowered
Disagree, doesn't really affect me
Agree, it bums me out a bit
Strongly Agree, totally bums me out
I eat what I want, when I want- whether it's healthy or not
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158
Discipline
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159
Forgiveness comes easy for me.
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160
Forgiveness
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161
I worry a lot and often feel anxious or nervous.
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Strongly Disagree
Disagree
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162
Worry
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163
I find myself focusing on the past.
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164
Stuck in past
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165
Other people hold me back in life.
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166
I surround myself with people who inspire me.
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167
Inspired
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168
I believe that words have power and I choose them wisely.
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169
Word power
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170
HIPAA Release
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By signing your name (using your finger, mouse or stylus), you are giving permission for DREAM Wellness to share your responses, results and report with your provider that is part of our VIP program.
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171
You have completed all of the questions for the DREAM Score! Do you currently have a copy of the book (or Kindle edition), D.R.E.A.M. Wellness: The 5 Keys to Raising Kids for a Lifetime of Physical and Mental Health, which is designed to help you implement the suggestions you will receive within the report?
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Yes!
Not yet but I absolutely plan to get my copy!
Not yet but I will probably get one.
I'm not sure what that book is.
No, and I'm not interested.
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172
Mental Wellness Total
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173
Total Points
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174
DREAM Score
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175
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