Heath Satisfaction Questionnaire

Health Assessment Questionnaire

Name: ______________________________________    Date: __________

Email Address: ________________________________________________

Please answer the questions on a scale of 1 to 10 , 1 representing that you don’t agree with the statement and 10 representing that there is no doubt in your mind or heart that you agree with the statement.

Physical Health

• I am a physically fit person and formally exercise on a regular basis.

1   2   3   4   5   6   7   8   9   10

• I have a physically attractive body that I am proud to look at in the mirror.           

1   2   3   4   5   6   7   8   9   10

• I have not had many traumas in my life (auto accident, broken bones, bad falls).  

1   2   3   4   5   6   7   8   9   10

• I get at least 7 hours of sleep, 7 days at week

1   2   3   4   5   6   7   8   9   10

• I have gotten regular Chiropractic care within the past 5 years.

1   2   3   4   5   6   7   8   9   10

Total ______

Emotional/Mental Health

• I am a calm, peaceful person. I can shut my mind off and focus my mind at will.

1   2   3   4   5   6   7   8   9   10

• I practice some form of mental relaxation (meditation, yoga, breathing exercises,  prayer, etc.) on a regular basis.

1   2   3   4   5   6   7   8   9   10

• Most of the time, I am truly happy and feel a sense of purpose in my life.

                   1   2   3   4   5   6   7   8   9   10

• I have healthy relationships and a rich social network of friends and activities.

                   1   2   3   4   5   6   7   8   9   10

• I am organized, have time for myself, and can prioritize the important tasks in my life. 

                  1   2   3   4   5   6   7   8   9   10                        

Total _______

 Chemical/Nutritional Health

• I eat 4-6 small meals daily and properly combine my protein, carbs. and fats.

1   2   3   4   5   6   7   8   9   10

• I supplement everyday with good supplements such as a vitamin/mineral          complex, antioxidants, and good fatty acids (fish oil, flax seeds).

1   2   3   4   5   6   7   8   9   10

• I do not take medications for chronic medical problems such as digestive       disorders; cardiovascular problems; headaches; chronic pain; blood sugar       problems; chronic fatigue; immune problems or chronic infections; or any other chronic conditions.

1   2   3   4   5   6   7   8   9   10

• I do not smoke cigarettes.

1   2   3   4   5   6   7   8   9   10

• I drink water as my primary beverage and consume at least 30 ounces per day.

1   2   3   4   5   6   7   8   9   10

Total________

Total of all 3 (physical, emotional, chemical) sections________________