LIFESTYLE ASSESSMENT

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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 Endtime Ministries Lifestyle counselors or associated organizations from any and all liability. Participation in this consultation indicates acceptance of these terms.

PLEASE FILL OUT ALL FIELDS

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DateToday's Date

Date

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Name

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Date of BirthDAY / MONTH / YEAR

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Sex

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Address

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Phone

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EmailAn email is required to submit form

example@example.com

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Martial Status

Single, Married, Divorced

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Height

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Weight

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Blood pressure

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Pulse

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Have you received the COVID vaccine?

If YES, how long ago?

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List health concerns.

physical, mental, spiritual, or social

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When did you last consult a physician?

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List ailments your are currently being treated for.

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List all prescribed medications and OTC supplements you are taking.

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List any surgeries you had

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What diseases have you been diagnosed with?

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Have you received any chemo or radiation treatments?

If YES, when and how long

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How many bowel movements do you have in a day?

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What specific conditions would you like this consultation to address?

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Do you read food labels?

YES or NO

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How often do you eat out?

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Are you on a special diet?

If YES, what kind?

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Do you usually eat bread less than 48 hours after it's baked?

YES or NO

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How often do you eat during the day?

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When is your last meal of the day?

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Do you exercise?

If YES, how many times per day and times per week.

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What kind of exercise?

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How would you rate your exercise?

Mild

Vigorous

Moderate

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How do you feel after exercise?

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Do you experience pain after exercise?

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At what temperature do you drink water?

Cold

Hot

Room temperature

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How much sun exposure do you get per day?

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Do you use sun block?

YES or NO

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Do you have any abnormal sensitivity to the sun naturally or due to any medication?

If YES, explain

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Do you take vitamin D supplements?

If YES, which one?

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What is your current occupation?

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Do you smoke?

If YES, how many cigarettes per day?

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Did you use tobacco in the past?

If YES, how much and how long?

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Have you been involved with substance abuse?

If YES, list them.

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List any addictions.

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Do you over eat?

YES or NO

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Are you a fast eater?

YES, NO, or SOMETIMES

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Do you snack between meals? (Includes food items and juice)

YES or NO

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List any desserts you eat.

Candies, Cakes, or Pies

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Please list the times you eat for all meals.Breakfast, Lunch, Supper

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How much time do you spend on leisure activities?

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Do you sleep with your windows open?

YES or NO

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Do you open your windows / doors daily to air out the home?

YES or NO

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Do you live in a smoke-filled environment?

YES or NO

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Do you have live plants throughout your home?

YES or NO

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Are there any environments that you are in that do not have a good supply of fresh air?

If YES, where?

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Do you wear tight fitted clothing that restricts your lung expansion?

YES or NO

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What is your usual bedtime?

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What are your working hours?

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Do you snack before going to bed?

YES, NO, SOMETIMES

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How many times do you urinate during the night?

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Do you struggle to go back to sleep?

YES, NO, SOMETIMES

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Do you sleep with lights on?

YES, NO, SOMETIMES

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Do you take sleeping pills?

YES or NO

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Do you rest from labor at least one day per week?

YES or NO

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Do you have daily devotional time?

If NO, would you like to have one?

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Do spend time reading your Bible daily?

YES or NO

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Do you believe in trusting the Lord with your problems?

YES, NO, or SOMETIMES

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Do you suffer from remorse, guilt, worry, or fear?

YES or NO

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Do you believe that you have experienced the forgiveness of God in your life?

YES or NO

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Do you struggle knowing God's will for your life?

YES or No

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Would you consider your family to have good relations with each other?

YES or NO

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Is your family spiritually strong?

YES or NO

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Do you have peace with God and your fellow men?

YES or NO

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Do you have a personal relationship with the Lord?

If Not, would you like to learn how to form a personal relationship with Him?