Lifestyle Assessment

3 Angels' Health Ministry

"Beloved, I wish above all things that thou mayest prosper and be in health, even as thy soul prospereth." 3 John 1:2
LIFESTYLE ASSESSMENT

CONFIDENTIAL
IMPORTANT

Please Note: The health information received during this consultation is for general education and is not intended to be specific medical advice. No medical care, diagnosis, or treatment is provided during this consultation. It is advisable to consult with one’s personal health care provider before implementing any lifestyle changes.
I release 3 Angels' Health Ministry’s Lifestyle Counselors or associated organizations from any and all liability. Participation in this Lifestyle consultation is strictly voluntary and indicates acceptance of these terms.

Signature: ________________________________ Date: _______________
Part 1. General Information
Full Name*

First NameLast Name
Best Contact Number*
Mobile
E-mail*
Address

Street Address

Street Address Line 2

CityState / Province

Post CodeCountry
What is your Church Affiliation? How long have you been a member?
When did you last consult a physician?
Are you currently being treated for any ailments?

YesNo
If yes, which ones?
Are you presently experiencing any of the following:

DizzinessNumbnessBad Body OdorFaintingClammy SkinExcessive SweatingNauseaCold Hands or FeetHair LossPainConstipationFeverHeart PalpitationsDiarrheaInfectionsFatigueIndigestionAcid RefluxBleedingHeadachesCold/FluWeight LossMemory LossBlurred VisionWeight GainInsominiaSwelling AnywhereSexual DysfunctionDifficulty BreathingParasites/WormsAnemia
What specific condition(s) would you like this consultation to address?
Age
Sex

MaleFemale
Marital Status

SingleMarried (1st, 2nd, 3rd or more)Divorced (1st, 2nd, or more)Widowed-Married (1st, 2nd, 3rd)Widowed-Divorced
Weight
Height
Please list all medicines you are currently taking?
Please list all supplements and/or herbs that you are taking (vitamins, minerals, nutritional drinks, etc...)
Part 2. Allergies
List Allergies
Part 3. Pure Air
1. Where do you live?
2. Do you sleep with your windows open?
3. Do you open your windows and doors daily to air out the home?
Part 4. Sunlight
1. How much sun exposure do you get per day?
2. Do you use sun blockers?
3. Do you have any abnormal sensitivity to the sun naturally or due to any medications?
4. Do you take Vitamin D supplements?
Part 4. Temperance
1. What is your current occupation?
2. Do you smoke, use tobacco products in any form (i.e. chewing tobacco)?
3. Did you use tobacco in the past?
If so, how much and for how long?
4. Do you live or work in a smoke-filled environment?
5. Do you have any smokers living in your home?
6. Do you use alcohol in any form?
If so, how much and for how long?
7. Do you ingest caffiene in any form? (e.g. coffee, teas, colas, energy drinks, etc.)
8. Do you eat at set meal times?
Please list times for all meals: (Breakfast, Lunch, Supper)
Part 5. Rest
1. What is your usual bedtime?
2. Do you wake up during the night?
3. Do you snack before you go to bed?
4. Do you sleep with the lights on?
5. Do you work the night shift or swing shift?
6. Do you wake up early in the morning and find it difficult to get back to sleep?
7. Do you take sleeping pills?
8. Do you rest from labor at least one day per week?
Part 6. Exercise
1. Do you exercise?
2. How many times per week? How many minutes per day?
3. What are your favorite exercise sessions?
4. Do you experience any pain while exercising?
Part 7. Proper Diet
1. Do you eat any meat or flesh items (chicken, turkey, pork, fish, shrimp, etc.)
2. Do you eat any dairy items or eggs (i.e. milk, cheese, yogurt, chocolate, etc.)?
3. If so, which ones?
4. How many servings of fruit per day?
5. How many servings of vegetables?
6. Do you use condiments (i.e. ketchup, mustard, mayonnaise, barbeque sauces, veggienaise, nayonaise, salad dressings, pickles, vinegar, etc.)?
7. Do you add any of the following spices to your foods: (cinnamon, nutmeg, cloves, curry, hot sauces, cayenne peppers, black and white peppers, etc.)?
8. Do you eat fried foods?
9. Do you use margarine or butter?
If so, how often?
10. Do you eat fresh bread? (bread eaten less than 48 hours after baking)
11. Which oils do you cook with?
12. Do you read the labels of food items that you buy from the store?
13. List any sweeteners you consume (i.e. sugar, honey, splenda, sweet&low, equal or additional artificial sweeteners, etc.)
14. Do you eat any canned items (beans, veggies, fruits, veggie meats, etc.)?
Which ones?
15. Are you on any special diet?
If so, details.
16. Do you eat out?
If so, how often?
Part 8. Water
1. How many glasses of water do you usually drink per day?
2. Is your water filtered?
3. At what temperature do you drink your water?
4. Do you eat ice?
5. How many glasses of juice do you drink per day?
6. How many cans/bottles of soda do you drink per day?
7. Do you drink with your meals?
8. What color is your urine normally?
Part 9. Trust in Divine Power
1. Do you have a daily devotional time?
2. If no, would you like to have one?
3. Do you have difficulty in trusting the Lord with your problems?
4. Do you suffer any remorse, guilt, worry, or fear at present?
5. Do you believe that you have experienced the forgiveness of God in your life?
6. Do you struggle with knowing God's will for your life?
7. Do you have a spiritually strong immediate family?
8. Do you have peace with God and your fellow men?
9. If the Lord were to come today, knowing the life that you are currently living, would you be saved? "Please answer this question within yourself."
Should be Empty:

LIFESTYLE ASSESSMENT

Part 1. General Information

Part 2. Allergies

Part 3. Pure Air

Part 4. Sunlight

Part 4. Temperance

Part 5. Rest

Part 6. Exercise

Part 7. Proper Diet

Part 8. Water

Part 9. Trust in Divine Power