Pillars Assessment - EPIC Functional Medicine

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Phone Number
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Date* This field is required.
Date
Month
Day
Year
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How did you hear about us?* This field is required.
Select your answer
Event
Google
Facebook
Referral
Other
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Who referred you?Hit Next If Does Not Apply
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Hydration* This field is required.Hydration 1. Hydration is less than half what it should be. Pop (soda)/ caffeinated drinks/ other processed beverages are also common. 2. Hydration is half or more to what it should be. Pop (soda) /caffeinated drinks/other processed beverages are fairly minimal. 3. Hydration is about 75% to what it should be. I drink mostly water (or some tea). 4. Hydration is often where it should be, but not every day. I drink mostly water (or some tea). 5. Hydration is where it should be, if not more, every day. I drink mostly water (with limited other beverages).
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Diet* This field is required. 1. I might eat 1-3 cups of veggies a day. Cow dairy, grains, processed foods, excess sugar, and/or high sensitive foods are consistently eaten. 2. I usually eat 3+ cups of veggies each day. Sometimes I eat foods I'm highly sensitive to or not on the EPIC Five Plan shopping list weekly. Sugar intake might still be a little too high. 3. I eat 5+ cups of veggies a day. I only eat foods I'm highly sensitive to or not on the EPIC Five Plan shopping list 1-2x weekly at most. If I am still a little high on sugar intake, it's mostly from fresh fruit 4. I eat 7+ cups of veggies a day, including all 3 categories. I rarely eat foods I'm highly sensitive to or not on the EPIC Five Plan shopping list. Sugar intake is usually below 30 grams daily (total from all sources), with berries being the main fruit. 5. I eat 9+ cups of veggies a day, including all 3 categories. I almost never eat foods I'm highly sensitive to or not on the EPIC Five Plan shopping list. Sugar consumption is no concern and my intake is consistently below 30 grams daily (total from all sources) - if I want something sweet, it's only berries.
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Movement* This field is required.1. Besides movement for chores / errands / work, I have limited/no intentional movement on any consistent basis. I feel I have no time, structure, or plan for movement. 2. I sometimes get 30+ min of intentional movement a few times a week. (This may include walking, cardio, HIITs, Strength Training, Flexibility / Stretching / Recovery, Sports, Phys Recreation, etc). 3. I am consistently getting 30+ min of intentional movement 3+ times per week. 2+/week of those include HIITs/cardio exercise, Strength Training, and/or Flexibility / Stretching / Recovery. 4. I am consistently getting 30+ min of intentional movement 5+ times per week. Included in that is 1+/week of each of the following: HIITs/cardio exercise, Strength Training, and Flexibility / Stretching / Recovery. 5. I am consistently getting 30+ min of intentional movement on a daily basis including 3+/week of each of the following: HIITs/cardio exercise, Strength Training, and Flexibility / Stretching / Recovery.
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Stress Management* This field is required. 1. I feel like I'm mostly in a constant "fight or flight" mode. I have too much to do to even think about stress reduction or something fun. I might have a little time for that on my days off. I have no structure or plan implemented for stress management. 2. I may get 20+ min of S.O.M.E. stress management or free time here and there a few times a week, but I know it isn't enough for me. There is still a big gap between my stress management and the things that drive my stress (or triggers) and how I personally respond to stress. 3. I get 20+ min of S.O.M.E. scheduled stress management at least four of the week. However, I would like to see additional improvement in the things that drive stress (or triggers) in my life and how I personally respond to stress. 4. I get 20+ min of S.O.M.E. stress management every day. I also get opportunities in my week to just enjoy myself/others. I feel like the drivers of stress in my life are not too big and are manageable. I know of and implement the tools needed to manage my personal response to stress (or triggers) when needed. 5. I get far more than 20 min of S.O.M.E. scheduled stress management consistently every day. I regularly enjoy my passions/ hobbies/interests throughout the week. On my average day, I have very little that drives my stress. I respond in a positive/constructive way to stress (or triggers) in my life.
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Sleep* This field is required.1. I have an inconsistent evening and sleep routine and I stay up too late. I know I would feel better if I just went to bed earlier (or woke up later) than I do now. 2. I have a consistent evening and sleep routine, but it's not enough time. I need to give myself more hours of sleep. 3. I have a consistent evening and sleep routine, and get at least 7+ hours of sleep. However, my sleep quality still isn't that great. 4. I have a consistent evening and sleep routine, and get at least 7+ hours of sleep. I sleep fairly well, usually. Sometimes I have off days, but mostly good sleep. 5. I have a consistent evening and sleep/wake pattern 7 days a week, and get 7+ hours of sleep. I sleep like a rock, and feel well rested the next day.
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Total EPIC Five Pillars
13
Tags
Todo
In Progress
Done
Should be Empty: