Aruka My Plan Lifestyle Questionnaire
Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Authentic Medicine
I receive care and have a personal relationship with the following medical professionals/doctors. I consider each a part of my healthcare team.
Please check all boxes that apply
Primary Care Physician
Dentist
Orthopedist
Optometrist/Ophthalmologist
Chiropractor
Acupuncturist
Herbal Specialist
Naturopathic Physician
Other
Are you happy with the healthcare team you listed above?
Yes
No
If no, please specify why.
Do you currently receive any health care from Eastern Medicine Professionals?
Yes
No
If yes, please specify.
Do you desire to learn more about Eastern medicine?
Yes
No
Do you currently receive any health care from Natural Medicine Professionals?
Yes
No
If yes, please specify.
Do you desire to learn more about natural medicine?
Yes
No
Inner Person
Have you taken the Aruka Worldview Survey?
Yes
No
Are there any areas of the Worldview survey that you answered but were unsure of that answer?
Yes
No
If yes, please specify.
Do you currently have problems with any of the following? Check all boxes that apply.
Mental Clarity
Focus
Self-Indulgent Thinking
Mind
Relaxation
On the following scale rate your level of daily stress – 1 least 5 highest
1
2
3
4
5
Do you struggle with anxiety daily?
Yes
No
Do you often struggle with guilt?
Yes
No
Do you have trouble forgiving someone who has wronged you?
Yes
No
Do you think you need assistance in controlling your emotions?
Yes
No
Do you have trouble in making decisions?
Yes
No
Do you believe people have a spiritual aspect to their being?
Yes
No
If seeking outside help in dealing with life issues I am most likely to turn to
A Psychologist
God
A Spiritual Advisor (Pastor, Priest, Rabbi, Iman)
A family member/friend
Myself
Other
Relationships
Do you feel you are a person who has healthy (good, strong) relationships?
Yes
No
Do you have trouble developing relationships?
Yes
No
Are you content with your current personality?
Yes
No
Do you think you are a good communicator?
Yes
No
Do you feel adequate in fulfilling all the various roles in your life? (example, mom, daughter, wife, friend, etc.)
Yes
No
Do you experience difficulty in performing some relationship roles more so than others?
Yes
No
If yes, please specify.
Do you have relationships that you would consider intimate?
Yes
No
Can you identify your "Fox Hole Friends"? (most reliable friends)
Yes
No
Do you consider yourself a "Fox Hole Friend" to some people?
Yes
No
Skill
Do you consider yourself a skilled person?
Yes
No
Do you have certain areas of your life in which you think you naturally flow?(things come easy)
Yes
No
If yes, please specify.
Do you place a high priority on work?
Yes
No
Do you practice any skills regularly?
Yes
No
Would you like to learn new skills?
Yes
No
Do you think you have a duty to apply your skills?
Yes
No
Do you have a desire to teach others your specific area(s) of expertise?
Yes
No
Do you consider yourself to be a person who possesses good self-esteem?
Yes
No
Nutrition
When drinking water at home, do you drink? Check only one.
Tap Water
Bottled Water
Filtered Water
If your answer was filtered water, can you list what type of filtration system youuse?
Do you feel like you drink enough water daily?
Yes
No
How many glasses of liquid would you estimate you consume a day, excluding alcohol?
Regarding food, which of the following would you say comprises the bulk of your eating?
Packaged/Processed Food
Fast Foods
Whole raw food – Unprocessed
A combination of all the above.
Do you have consistent problems with any of the following.
Indigestion
Gas
Bloating
Overeating
No appetite
Other
How many meals a day do you eat?
1
2
3
4
5
6
Do you consistently skip meals?
Yes
No
Do you snack between meals?
Yes
No
Do you get consistently become hungry between meals?
Yes
No
Are you currently on a diet?
Yes
No
How would you rate your current eating habits?
Poor
Average
Good
Do you currently practice any form of fasting?
Yes
No
How many units of alcohol do you drink per week? (1 unit = 1 glass, of beer, etc.)
Do you monitor the amount of sugar you consume?
Yes
No
Do you consume any natural supplements? (vitamins, minerals, herbs, etc.)
Yes
No
If so, please list the supplements you currently take below.
Do you think you are disciplined in your approach to what you consume?
Yes
No
Have you ever utilized the services of a nutritionist, dietician, or other medical professional?
Yes
No
Exercise
How many hours on average do you work each week?
How do you spend most of your time at work?
Standing
Sitting
Driving
Active
How would you describe your current activity level?
Sedentary
Moderately Active
Active
Highly Active
How would you rate your present level of fitness?
Unfit
Moderately fit
Fit
Highly fit
Are you currently involved in a regular and consistent exercise plan?
Yes
No
How often do you perform exercise weekly?
Once a week
2 x a week
3 x a week
4 x a week
5 x a week
6 x a week
Daily
How long have you been involved in a consistent exercise plan?
What type of exercise do you do?
When exercising, how long on average are your training sessions?
If you were to describe the intensity in which you approach exercise, would you say it is.
Leisurely
Recreational
Competitive
Do you enjoy experiencing different forms of exercise?
Yes
No
Have you ever employed a coach or personal trainer to assist you?
Yes
No
What is your favorite form of exercise?
Restoration
Have you ever utilized a detoxification or cleansing program?
Yes
No
If yes, please specify.
Are you interested in learning more about environmental toxins and their effect on the body?
Yes
No
On average, how many hours of sleep do you get at night?
Do you have trouble falling asleep?
Yes
No
Do you wake up numerous times during the night?
Yes
No
Do you practice meditation or prayer?
Yes
No
Do you listen to music on a regular basis?
Yes
No
What is your favorite type of music?
Have you ever had a hormonal blood panel test?
Yes
No
Do you on a regular or irregular basis have any type of soft tissue therapy administered?
Yes
No
If yes, please specify.
Do you suffer from muscular or joint pain?
Yes
No
Have you ever been analyzed for movement dysfunction?
Yes
No
Are you interested in forming a proactive health management plan that parallels and works together with your current medical plan?
Yes
No
Readiness Assessment & Health Goals
Rate on a scale of 1 (NOT WILLING) to 5 (VERY WILLING)
Improve your knowledge of medicine.
1
2
3
4
5
Make changes in the way you think about your health.
1
2
3
4
5
Address the areas of stress that adversely affect your health.
1
2
3
4
5
Learn new skills that can enhance your health.
1
2
3
4
5
Significantly modify your diet.
1
2
3
4
5
Take several nutritional supplements a day.
1
2
3
4
5
Engage in a new or modified exercise plan.
1
2
3
4
5
Modify your lifestyle (sleep, work demands,etc.)
1
2
3
4
5
Practice a form of restoration (massage, detox, meditation)
1
2
3
4
5
Rate on a scale of 1 (VERY UNSUPPORTIVE) to 5 (VERY SUPPORTIVE)
At the present time, how supportive do you think the people in your household will be to your implementing the above changes?
1
2
3
4
5
Rate on a scale of 1 (VERY FREQUENT CONTACT) to 5 (VERY INFREQUENT CONTACT)
How much ongoing support from our professional staff would be helpful to you as you implement your personal health program?
1
2
3
4
5
Any Comments:
Submit
Should be Empty: