Assess your lifestyle programme by Dr.E. Anthony Allen

Patient Lifestyle Assessment and Progress Chart

Copyright© E. Anthony Allen 2008

This response sheet is designed to assist the doctor in your follow-up, as well as to help you in your own self-assessment. Insert relevant numbers or Y = yes, N = no. Use average for numbers as applicable.
Date

MonthDayYear
Date
Regular Exercise
Times per week
Minutes each time
Relaxation Exercise
Times per day
Daily Rest (weekdays) minutes/hours taken
Daily Rest (weekends) minutes/hours taken
Hours of Sleep Nightly
Recreational Activities
Times per month
Current regular hobby

YesNo
Reaching out to Friends and/or Relatives (for mutual support)
per day / per week / per month
Voluntary Service
per month per quarter
Reaching out-Spiritual
Scriptures (times weekly)
Prayer (times weekly)
Place of worship attendance (times monthly)
Makes use of activities for fellowship, education and support at place of worship?

YesNo
Nutritional Self-Care
Uses most groups of plant based food, and mostly unprocessed

YesNo
Eats 5-7 servings of vegetables and fruits daily

YesNo
Eats more vegetables than starches

YesNo
Generally avoids processed or refined grain products

YesNo
Mostly avoids red meats

YesNo
Mostly avoids other parts of non-organically grown chicken, except breast

YesNo
Includes mostly: fish or plant based protein products as dietary protein

YesNo

Generally avoids the following foods:

	Yes	No
Sweets (except fruits & vegetables)
Salty
Fried
Fatty
"Junk Foods"
High fat dairy products (e.g. butter, cheese, milk, egg yolk)
Soft Drinks

Supplements taken daily:

Sunlight: 15 minutes daily

YesNo
Current weight
In appropriate weight range for my height:

YesNo
Safe sex Practiced: (Condom, or abstinence, or mutual fidelity)

YesNo
HIV status known

YesNo
Substance Avoidance (e.g. cigarettes, excess alcohol, drugs)

YesNo
Smoking: No. of cigarettes
Most of Socio-economic habits: -improving productivity skills -budgeting -saving -planning

YesNo
Annual check up completed (if over 25 years):

YesNo

Thinking in whole person terms

	None	Mild	Moderate	Marked
Degree

Patient Lifestyle Assessment and Progress Chart