Employee Wellness Project

Personal Health Assessment

The purpose of this assessment is to determine your risk of developing the degenerative diseases common among Americans. Although diagnostic testing can sometimes be important, the best testing can do is to detect disease at an early stage. A complete inventory of your diet and lifestyle can help you to determine whether or not changes need to be made in order to avoid becoming ill. It is always easier to prevent disease than to recover from it.

Part I: Diet

I Eat Breakfast: __________

Every day; 0 points

Most days; 1 point

Rarely; 2 points

Never; 3 points

I eat _____ meals per day

5-6; 0 points

4; 1 point

2-3; 2 points

1; 3 points

I eat _________ servings of fruit per day

3-4; 0 points

2; 1 point

1; 2 points

Usually none; 3 points

I eat ________ servings of vegetables per day

8-9; 0 points

6-7; 1 point

5; 2 points

Fewer than 5; 3 points

I eat _______ servings of whole grains per day

3 or more; 0 Points

2; 1 Point

1; 2 Points

Less than 1 per day; 3 Points

I eat ________ servings of legumes per week

5 or more; 0 points

3-4; 1 point

1-2; 2 points

Fewer than 1; 3 points

_______

I eat foods containing ingredients like refined sugar, enriched flour and other negative ingredients:

Almost never; 0 points

1-2 times per week; 1 point

3-4 times per week; 2 points

More than 4 times per week; 3 points

_______

I consume artificial sweeteners:

Never; 0 points

Occasionally; 1 point

Weekly; 2 points

More than one time per week; 3 points

_______

I consume fast food:

Never; 0 points

Occasionally; 1 point

Weekly; 2 points

More than one time per week; 3 points

_______

I consume soft drinks:

Never; 0 points

Occasionally; 1 point

Weekly; 2 points

More than once per week; 3 points

_______

I consume animal foods (beef, dairy, chicken, eggs, fish, etc.):

Never; 0 points

1-3 times per week; 0 points

4 or more times per week; 4 points

5 or more times per week; 5 points

(If not a vegetarian) I eat organic animal foods and wild fish:

Always; 0 points

Sometimes; 3 points

Never; 5 points

I consume dairy products:

Never; 0 points

Weekly; 2 points

Daily; 3 points

More than once per day; 5 points

I drink 64 ounces of water:

Daily; 0 points

Most days; 1 point

Rarely; 2 points

Almost never; 3 points

I drink the following types of water:

Carbon filtered; 0 points

Bottled with minerals; 0 points

Bottled w/o naturally occurring minerals; 2 points

Tap water; 3 points

Reverse osmosis or distilled; 3 points

I drink alcohol:______

1 time per week or less; 0 points

2 times per week; 1 point

I consume oils (in salad dressings, cooking oils, in packaged foods):_______

Almost never; 0 points

Several times per week; 1 point

Once per day; 2 points

More than once per day; 3 points

I drink coffee:________

Occasionally; 0 points

Weekly; 1 point

Daily; 2 points

More than one cup per day; 3 points

Smoking: _______

I have never smoked; 0 points

I quit over 5 years ago; 0 points

I quit less than 5 years ago; 1 point

I quit less than one year ago; 2 points

I currently smoke; 5 points

Sleep Habits:_______

I regularly go to bed between

10:00 and 11:00 PM; 0 points

I go to bed after 11:00 PM; 1 point

I go to bed after 12:00 AM; 2 points

I need an alarm clock to wake up; 3 points

I fall asleep easily when I watch TV or read; 4 points

3 times per week; 2 points

4 times per week; 3 points

Stress:

Please check off those issues that are currently causing you stress:

__ Children __ Low self-esteem

__ Parents __ Divorce/separation

__ Spouse/significant other __ Moving

__ Work circumstances __ Not looking the way you want

__ Co-worker __ Boss

__ Traffic __ Lack of exercise

__ Lack of sleep __ Financial

__ Physical illness __ Not enough hours in the day

__ Unfulfilled expectations __ Can’t say no

__ No time to yourself

Assign one point for each item you checked above ___5____

Relationships: ______

I engage in social activities:

At least once per week; 0 points

Fewer than once per week; 1 point

Once per month; 2 points

Rarely; 3 points

Marriage/significant other: ______

I am happy being single; 0 points

I am happily married; 0 point

I am happy in a committed relationship; 0 points

I am single and unhappy; 2 points

I am married and unhappy; 2 points

I am in a relationship and unhappy; 2 points

Friends: ______

I have supportive friends; 0 points

My friends could be more supportive; 1 point

My friends are not supportive; 2 points

I need to make new friends; 3 points

General relationship: ______

Most of my relationships with others are good; 0 points

Some of my relationships need improvement; 2 points

I often have conflicts with other people; 3 points

Job/Career: ______

I like my job; 0 points

I like only parts of my job; 1 point

I wish I had a different job; 2 points

I wish I had a different career; 3 points

Personal: ______

I like myself; 0 points

I like some aspects of myself; 1 points

I need to make major improvements in myself; 2 points

I don’t like myself; 3 points

Outlook: ______

I am very optimistic; 0 points

I am usually optimistic; 1 point

I often feel pessimistic; 2 points

I tend to be pessimistic; 3 points

Outlook Part II:______

I have a good sense of humor; 0 points

I can sometimes laugh at life; 1 point

I have trouble maintaining my sense of humor; 2 points

I generally do not have a good sense of humor; 3 points

Exercise:_______

Number of days you work out:

I work out 5 or more days/week; 0 points

I work out 4 days per week; 1 point

I work out 3 days per week; 2 points

I work 2 times/week or less; 3 points

Length of each workout:

My workouts are 45 minutes or longer each; 0 points

My workouts are 30-40 minutes; 1 point

My workouts are 15-25 minutes; 2 points

My workouts are less than 20 minutes; 3 points

_______

I spend ___________ minutes in my target heart zone during each workout-0 points

45 minutes or more- 1 point

30-40 minutes- 2 points

20-30Less than 20- 3 points

I do weight training:_______

2 or more times per week- 0 points

1 time per week- 1 point

A couple of times per month- 2 points

Rarely- 3 points

Part I Sub-Total ......................................................................... ___53____

Part II:

Assign 3 points for every item checked below:

Do you often wake up feeling tired?	3
Do you regularly experience fatigue during the day?
Do you feel that you should be more energetic?	3
Do you suffer from frequent headaches or migraines?
Are you more than 10 pounds overweight?	3
Do you have too much body fat?
Does your weight fluctuate often?
Do you experience lack of mental clarity or memory loss?	3 ADD
Do you have problems with digestion?
Do you have gastrointestinal problems?
Do you have constipation on a regular basis?
Do you have asthma?	3
Do you have allergies?	3
Do you frequently get colds, sinus congestion or flu-like symptoms?
Do you experience bouts of depression or anxiety?	3
Do you have arthritis?
Do you suffer from any autoimmune disorders?
Do your joints hurt?
Do you have trouble going to sleep or sleeping through the night?
Are you experiencing menopausal symptoms?
Do you frequently experience food cravings?	3
Do you frequently eat when you are not hungry?
Do you often feel stressed out?	3
Do you ever feel bloated or uncomfortable after eating?	3
Are you taking over-the-counter medications regularly?
Do you take pharmaceutical drugs?

Part II Sub-Total ………………………………………………………………………………………_____33______.

Total points for survey……………………………………………………………………………______83_____!

Scoring System

Under 20 points	You are doing a great job. Of course, it would be best if you scored no points, but no one is perfect! Keep working at maintaining dietary excellence and optimal habits.
21-35 points	Although you are doing a lot of the right things, your risk of developing degenerative diseases is elevated and there is room for improvement.
36-50 points	Your diet and lifestyle are in need of improvement in order to reduce your risk of diseases like cardiovascular disease, cancer and diabetes. Best to start now!
51-65 points	Immediate changes are needed, as your risk is quite high.
66 or higher	You are in the highest risk category for developing conditions associated with poor diet and lifestyle.

Dietary Excellence and Optimal Habits

Guidelines for diet:

· Start the day with a healthy breakfast, and eat several small meals throughout the day.

· Consume a plant-based diet with 90% of calories from fruits, vegetables, whole grains and legumes.

· Consume animal foods sparingly, and eliminate cow’s milk products

· Make water your first choice beverage and drink at least 64 ounces daily

· Reduce your consumption of processed and highly refined foods

· Increase your fiber consumption

· Decrease fat consumption

Guidelines for living:

· Go to bed early! An hour of sleep before midnight is worth two hours after.

· Change situations that cause you stress or change your response to stress.

· Take a personal inventory and improve those things that would help you to feel better about yourself.

Exercise:

· An optimal plan includes spending 45-60 minutes in your target heart zone 5-6 days per week.

· A combination of weight training, aerobic exercise and stretching is best.

Symptoms:

· Symptoms like fatigue, digestive disorders and excess weight are signs that you need to make improvements in your diet and lifestyle. Do so before you develop a serious health condition, it is easier to prevent than reverse disease!