Health Rating Form

Health Rating Form

Rate your health with this form and generally suggested massage and wellness plan. This health survey is to gauge your stress and tolerance to stress as well as look for any noticeable symptoms of cardiovascular or gastrointestinal problems that can present on a physical examination.
Name*

First Name Last Name
Email*

Confirmation Email example@example.com
Today's Date*

MonthDay Year
Date
Please fill out this in depth personal health survey to gauge your health routine and how much benefit you would receive from massage therapy and being placed on a better wellness plan and monitored frequently with basic blood pressure monitoring and oxygen sensor, and tape measure device. None of this information is shared anonymously or other. This is for your own health record and develop the best massage and wellness plan for you. It takes less than the free 30 minutes delivery time to and 30 minutes delivery time from any massage address location. You can do this why you wait for your massage therapist to arrive at your location.
1. How have you been sleeping in the last six months?*

no problems falling asleepneed to take a sleep medicine to sleeppattern changes with few nights 4-6 hours per night6-8 hours of sleep per nightdon't stay asleep the whole night
2. How would you rate the amount of stress you deal with daily? (Stress is very dangerous if not managed, because it leads to creating more cortisol in our bodies when low on blood glucose, called gluconeogenesis, and it involves breaking down fats into fatty acids that are converted by the liver into triacylglycerols to make lipoproteins that also contain cholesterol from the liver and gallbladder to send to the body's muscle needs that can lead to clogged arteries and heart disease. Stress is also a vasoconstrictor so many of the body tissues will be slowed down on nutrient needs to build and repair damaged tissues and maintain the body's cellular respiration needs)*

I work everyday and am stressed each daylow stress, work, kids, spouse, house all greataverage stress, only when driving, waiting at a drive-thru, at work waiting on the phonehigh stress, constantly waiting on others and no breaks or breaks listening to dramano stress, I do everything myself, exercise, diet, sleep fine, have nothing that bothers me, people in my way, driving, waiting on the phone to speak to clients or pay bills and setting up services doesn't bother me
3. How many minutes of Sun do you get each day? (Vitamin D is obtained from the sun and needed for cellular repair and proper function in many systems of the body such as the endocrine and skeletal and musculature and cardiovascular systems.)*

I exercise outdoors for 30 minutes or more with walks, bicycling, playing sports, or gardeningI am allergic to the Sun and don't go in the Sun if I can avoid itI am sensitive to heat and choose not to go out in the Sun if its a hot dayI swim in my pool or go to the beach on weekends or my days offI only get about 15 minutes of Sun each day from walking to the stores or office from my car arriving, lunch time, and leaving
4. How is your diet on a regular day? (Your ratio of carbohydrates to fats and protein intake as a daily ratio. Cholesterol has a range of 100+ to 800 mg/day, saturated fats are solid fats like butter and animal fats like bacon, fiber is necessary to eliminate excess cholesterol from the diet, unsaturated fats like omega 3s in fish oil and flax seed oil or walnuts have the 'good' cholesterol, HDL, that helps to prevent hardened arteries by cleaning up excess saturated fats and being an anti-oxidant that prevents the heart disease cholesterol from forming plaque in the arteries that causes hardened arteries and high blood pressure. Having a high protein diet isn't necessarily healthier or lead to a less stressful health mindset as the body will be put in a fasting mindset and burn up any fat in the body for energy when blood glucose is low and protein has less energy than fat per gram and leads to low blood glucose as well as using that burned up fat in the body to make lipoproteins with liver enzyme's hepatic lipolipase that creates the 'bad' cholesterol, LDL, in the blood that can form plaque in arterial walls as gluconeogenesis derives energy from the body by breaking down triacylglycerol from the fatty acids (1 glycerol to 3 fatty acid chains) in fat it breaks down, pyruvate from dietary glucose in the blood after eating or the breakdown of glucogenic amino acids, lactate from muscle energy demands not met after intense exercise, and amino acids from the breakdown of proteins in the body. Everything in moderation is the goal for our diets.). Idea diet should be 40-65% carbs with half veggies, fruits, and fiber, 10% saturated greasy fats is actually recommended for our cells and corticosteroids, 10% unsaturated fats to clean up excess grease in vessels, and only 15-30% protein as no protein is used for energy, only to make enzymes, repair cells, and build muscles. We actually need carbs for energy to supply those processes and for cellular energy with oxygen.*

40-50% carbs, 0-10% fiber, 10% saturated fats, 10% unsaturated fats, 30% protein50-60% carbs, 0-10% fiber, 0-5% saturated fats, 10-15% unsaturated fats, 20% protein30-40% carbs, 0-10% fiber, 20% saturated fats, 0% unsaturated fats, 40% protein30-40% carbs, 0-10% fiber, 0% saturated fats, 20% unsaturated fats, 40% protein10-20% carbs, 0-10% fiber, 5% saturated fats, 10% unsaturated fats, 65% protein
5. Do you take any supplements to enhance your health? (Supplements are necessary as we need essential vitamins like vitamin B-12 to have proper red blood cell function, vitamins for many systems of the body, and minerals that our body needs for better function as well as protein to build more proteins like enzymes and antibodies or fiber to eliminate damaging toxins and waste products from our bodies through our bowel movements.)*

proteinmulti-vitaminvitamins C, D, E, A, K, B-complex, minerals, multivitamin, othersminerals like iron, calcium, magnesium, or copperamino acids like branched chain amino acids, glutathione, glutaminefibernone
6. How is your digestion by how often do you have bowel movements or poop? (It is important to rid our bodies of waste daily as it lowers cholesterol and toxins from our blood and body tissues.)*

after waking upafter eating or sometimes after eatingeveryday at some point in the dayevery other dayLess than three times a weekmore than 3 times a day
7. When you have a bowel movement, what is the quality of it? (Don't show me, but this is important to understand your own health.)*

dark like tar but solid (could mean upper GI tract infection (Melena), or ulcers in GI tract, cancer risk if changes don't go away), or white without color (jaundice from unconjugated bilirubin being excreted in feces)spastic normal color but not solid (could be ibuprofen or NSAID abuse damaging intestinal upper GI tract prostaglandins that protect lining, stress, IBS, other)not dark or light and solid (normal to some diets)not dark or light and not solid (normal to some diets)not a full load and feeling bloated (tenesmus, possibly dehydrated and not taking a lot of fiber)can't fart because afraid might poop in pants (obstipation, intestinal blockage, stress and possible old age or taking too many stimulants or greasy bowel movements due to gall bladder infection or blockage in gall bladder ducts or pancreatitis, could also be an intestinal blockage)blood in the toilet (lower Gastrointestinal infection, hematochezia, like diverticulosis is possible, cancer risk if changes don't go away)blood on the toilet paper (hemorrhoids from dehydration and not taking enough fiber)fat in stool, gray or pale white color (could indicate upper gastrointestinal tract disfunction from improper bile delivery from liver or gall bladder, high fat diet where fats aren't getting digested. Tell-tale if jaundice in eyes or upper abdominal pain on right side below and at bottom ribs when holding and digging in while exhaling and inhaling.mucus, pus, or blood in feces/poop (inflammation, can be with diarhea, less than 2 weeks is infection, more than 2 weeks is likely Crohn's Disease or Ulcerative Colitis)
8. How would you describe the quality of your body pain, if any, that made you inquire about a massage for your general health today?*

throbbing (vascular pain likely)diffuse (not localized) and/or aching (vascular or musculature pain likely)dull (not localized) pain (musculature pain is likely)referred pain to skin but not a wound on skin (visceral or organic pain is likely)burning pain (muscular or organic/visceral pain is likely)boring/drilling pain that is localized (bone pain is likely)deep, localized pain (organic or bone pain is likely)sharp, shooting, bright, pricking, ants crawling, refers along a dermatomal or peripheral nerve path (nerve pain is likely)no pain anywhere in bodygnawing or tearing pain (could be the organ capsule being stretched like lymphoma or pyelonephritis in kidney region)
Annotate Image in light ink where pain is.
Annotate Image below in light ink where pain is.
Annotate Image in light ink where pain is.
Annotate Image below where pain is in light ink.
Annotate Image where pain is in light ink.
Annotate Image with light ink where pain is.
9. How is your cardiovascular health? Please pick all the following tell-tale descriptors that apply to your health.*

I get paresthesia or a loss of feeling or tingling sensation in any of my limbs when sitting for a while.One of my arms is noticeably wider than the other armOne of my legs is noticeably wider than the other legWhen I put my hand on my upper belly I can feel my abdominal aorta right above and to the sides of my belly button without pressing on my belly.I get dizzy when I stand up too fastI got hit in the head or in a car wreck recently and now I get vertigo and/or double visionI can put my hand on my chest like when saying the pledge of allegiance and noticeably feel my heart thump out its chest and sometimes it sounds the way a cat purrsI don't have any tell-tale signs of cardiovascular disorders, and last time I checked my blood pressure was around 120/80. No hypertension, pre-hypertension, low blood pressure, or high pressure.I don't have any tell-tale signs of cardiovascular disorders, but don't know my blood pressure reading.pain in chest or left shoulder after exercise that goes away afterwards
10. How often are you stretching each day? (Stretching is necessary for great body function, to help breakdown muscle and fascia adhesion lesions between layers of muscle, to enhance deep breathing that relaxes the autonomic nervous system and helps to initiate the rest and digest response to life situations and events.)*

rarely to neverwhen sitting or standing or around the time I exerciseonly after working out or before itonly when waking uponly after driving for a long road trip
11. How do you rate your energy levels during the day? (Energy is a good indicator for good health, and poor energy levels or drainage could be due to diet, stress, poor mineral and essential amino acid consumption needs of the body, infection in the body is indicated by fatigue and low energy levels, not getting enough sleep, or substance dependence or depression can be indicated by fluctuating energy levels or low energy.)*

most energetic in the morningmost energetic by lunch timemost energetic by the time I leave for work or daily activitiesmost energetic right before bedtime or when trying to go to sleepmost energetic when I had my coffee, energy drink, or teaenergy levels are the same every day and don't change but sensitive to diet and sleep pattern changestired all the time
12. How is your consumption of caffeinated drinks?*

I drink a cup of coffee or have an energy drink in the morning onlyI drink a cup of coffee or energy drink in the morning and another at lunch timeI drink more than 2 cups of coffee or energy drink more than a few times a week to get me through the dayI don't drink caffeinated beverages at allI only have decaffeinated coffee or tea before bedtime
13. How many alcoholic drinks in servings do you drink per day, week, month, year?*

01, 7, 30, 3650, 0, 0, 65, 20, 40, 480
14. How many soda or high fructose flavored and sweetened drinks do you drink a day? (Drinking artificially sweetened drinks that have been flavored with artificial fructose is incredibly bad for your health as it lowers your body's ability to make sorbitol dehydrase to break down the disaccharide, sucrose, into glucose and fructose in the body and is a great contributor to type 2 diabetes that makes the cells retain water and lose functionality due to the osmotic pressure disturbances of sorbitol building up in the cells. This cellular disfunction affects the nerve sheaths, the retinal arteries, the nephron tubes of the kidneys as well as other cells in the body vital for good health. Those disorders are associated with peripheral neuropathy, retinopathy, and nephropathy.)*

only 1 with lunchonly 2 with lunch and dinnerneveronly on special occasions or with pizza or fried foods that is rarelyonce in a while but only if its in the fridge but I never buy itnot as much as my water intakeonly the soda that is included in my energy drink question earlier
15. How often are you taking Ibuprofen, Tylenol, or Aspirin for pain? (Long term use of these over the counter drugs can damage the liver and kidneys that are vital organs in mortality and good health. Overuse of Ibuprofen can damage the liver as badly as alcohol abuse and lead to Irritable Bowel Syndrome (IBS) from destroying vital prostaglandins in the gut that regulate digestion. Tylenol abuse can damage the hormones involved in body fluid regulation done by endocrine system and kidneys. An Aspirin a day is prescribed to thin blood in heart disease patients suffering clots but abuse of it can also cause endocrine disfunctions in the body.)*

The recommended dose 4 times a day for the last weekthe recommended dose only as needed when autoimmune symptoms or arthritis flares upthe max daily dose for the last 20 yearsonly a few times a week or monthly but not every day or weeknever or very rarely as in once a month, when tooth pulled, surgery, etc.
16. Do you smoke? (Smoking is publicly known to cause many different cancers like lung and oral tongue and lip cancers. It is often used to deal with stress to calm ones nerves or allow them to renew their mind on a break and could be used as a quick fix in the short run, but long term, this addiction is highly associated with permanent disability or even death from having a stroke.)*

only weed and as neededonly weed and for many yearscigarettes and weed on the daily for many yearscigarettes only and for many yearsonly cigars and on special occassionsnot a smoker, don't smoke anything
17. How is your urinary system health? Please select any of the following options to describe your urinary health.*

I have to pee frequently (sign of infection if a new change, antidiuretic hormone ADH insufficiency with endocrine glands of adrenal and pituitary or hypothalamus, kidney disease)I am always thirsty and pee frequently (sign of diabetes, peeing frequently is sign of infection if more than normal with amount of fluids consumed)I get up once during the night to pee only if I had a glass of water before sleepingI get up frequently during the night to pee (sign of diabetes or other serious disorder of the heart, liver, or kidneys lacking sufficiency in emptying excess water and only able to when body is lying down with less effects of gravity in day when sitting or standing. Examples are edema in the limbs and abdomen from congestive heart failure, liver disease, or kidney disease from inability to collect and retain fluids to pee)I feel pressure on my perineum area of muscles that radiates along my groin (could be prostate stones that are benign, or enlarged prostate from prostate cancer)I have flank pain and when someone runs into me in the back or side even slightly, it aches and makes me grimace in pain or yell out in pain then it goes away (sign of kidney stone or kidney infection)I always feel like I have to pee but only a little bit of pee comes out (high frequency and low volume is sign of infection like a urinary tract infection (UTI).)I have slight incontinence when laughing, sneezing, coughing, jumping, or exercising (sign of bladder insufficiency with a strong detrusor muscle of bladder and weak urethra sphincter, tumor pressing on bladder, neurological like Multiple Sclerosis, Parkinson's Disease, Dimentia, peripheral neuropathy like cauda equina low back injury, or stroke)there is blood in my pee (sign of infection, kidney or bladder or urethral stone, menstruation)I feel like I have no problems peeing and am not worried about how often I peeI don't have any problems with how frequently I pee or the quality of my pee or quality of my body when peeingWhen I pee I can't empty it fully and keep dribbling or can't maintain a steady stream of pee (could be sign of prostate stones or enlarged prostate that is a potential risk for prostate cancer.)
18. How often are you eating foods that have been barbequed or prepared so that the outside is covered in black or dark burnt shell that you eat as is without picking off the burnt portions? (Blackened or burnt or charred foods is a known carcinogen that leads to a high risk of developing cellular repair malfunctions that lead to various cancers. Best to avoid barbequed or charred foods or at least minimalize them and take off the burnt portions. Even burnt vegetables like peppers are toxic to your health.)*

rarely to never2-5 times a week regularly1 time a week regularly2-6 times a year for special eventseveryday
19. How often are you stuck in one spot stressed like driving and switching lanes between road blockers and free lanes, waiting on the phone on hold and having technical devices break, freeze, or pause when working on a deadline, having to finish up reports, arguing with a person, not getting a word in, having the wrong item delivered that you didn't buy, etc.?*

40 hours a week, 8 or more hours a day for work20 hours a week commuting plus 40 hours a day at work10 hours commuting and 40 hours a day each weekbetween 5-10 hours commuting and 40 hours a day each weekless than 5 hours commuting and 40 hours a day each weekonly for work, from home 40 hours a weeknever or rarely by less than 5 hours commuting each week and work doesn't involve stuck in one spot or position like sitting at a desk or standing at a work stationI am never stuck in a stressful situation on any regular amount of time, and those listed items don't make me stressed at all because I am used to them and know that my health isn't paying for this but their wallet is or know its an unavoidable task that has to be done.
20. How often do you exercise for at least 30 minutes, this includes cleaning the house, doing lawn work, moving furniture, as part of work if it involves lifting weight and moving your body? (Exercise is necessary every day by doing at least 30 minutes it can help prevent type 2 diabetes, reduce risk of heart disease and hypertension, improve balance and coordination, reduce risk of osteoporosis or bone density loss, increase energy levels, help sleep improve each night, and more.)*

less than dailyonly on the weekends3X a week5X a weekevery day and lose my mind if I don't get my workout innever
21. How would you say your balance and coordination are when sitting? (This is an indicator of cerebellar and cortex brain diseases like upper motor neuron disorder of the corticospinal tract or ataxia, or long-term alcohol abuse.)*

I can extend my finger out in front of my nose and touch my nose every time with both arms simultaneously or at the same time without missing my nose. I can do this with my eyes open and closed at least 30 seconds with each arm.Not the best, when I try to touch my nose with each arm, I don't always land on my nose from my arm extended in front of me with both arms, one at a time, with my eyes open and definitely not with my eyes closed.I can extend my arm out in front and touch my nose and bring it back for 30 seconds for both arms and with my eyes open but not closed, and land on my nose each time and with each arm.I start to shake when trying to touch my nose with eyes open or closed in one arm or both arms
22. How coordinated is your balance when standing or walking across the room? Try walking along a line 5 steps in front along a line, then turn around and walk across the room along the line with your eyes closed. Put one foot in front of the other in tandem each step. (This is an indicator of possible cerebellar diseases, vestibular-ocular reflex disorders, drug/alcohol abuse, and others)*

I have to do it with my eyes open and arms out to the side for balanceI am unable to walk with a foot in front of the other heel to toe in tandem with my eyes open or closed and feel like I might fallI am unable to tell how my balance is walking in tandem with eyes open or closed because I am scared I will fallI am able to do this without any problems closing my eyes or opening them and use my arms for balance.
23. For your vestibular ocular reflex (VBO), look in front of a mirror while you do this or take a cell phone video of your eyes when doing this. look to your left without moving your head, then look to your right without moving your head, and only moving your eyes, does one eye shift fast or much slower in either direction (nystagmus is the eye that moves fast to the side, strabismus is if it moves slowly to the side or not at all)?*

both eyes move to the side without a shift in speed faster or slower for either eyeballmy right or left eye shifts faster and keeps moving a tiny amount of time before stopping (nystagmus of left eye when looking to the right, could be indicator for brain stem trauma, drug/alcohol use, genetic disorder, or sign of history of stroke or trauma)one of my eyes when looking right or left doesn't move outward to the side (lateral rectus muscle and cranial nerve 6-abducens nerve injury or pons of the brainstem injury or medial longitudinal fasciculus motor pathway damage same side of 'lazy eye.' Could be sign of trauma, stroke, or other damage)one of my eyes when looking inward when looking to the other side is lazy and doesn't move (trochlear nerve-cranial nerve 4 of midbrain damage to the superior oblique motor muscle to eye ball, or medial longitudinal fasciculus motor pathway damage. Could be sign of trauma or stroke in history.)double vision (diplopia) could be sign of more serious disease like myasthenia gravis, internuclear opthalmoplegia (INO)
Results of survey questions on personal self health:
If you scored between 80 or higher on this survey, then your overall generally healthy, but a regular massage included in your regular health routine is going to improve your health and wellness outcomes.

If you scored between 0-80, then your health needs work, and a regular massage can be included into your health and wellness routine to improve your health and quality of life.

If you scored less than 0, you really need to make some lifestyle changes and having a regular massage and someone who can monitor your health and track improvements will give you a better quality of life and make you less stressed or better able to handle stress in your life and in any situation.

Thank you for filling out this form. Someone will contact you soon. Have a great rest of your day.
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