Life Balance Corp. - Life-Scan On-Line

Life Balance Health Assessment - Life Scan On Line

Stress Assessment
1	I worry a lot	Never Seldom Sometimes Frequently Always
2	I feel unhappy.	Never Seldom Sometimes Frequently Always
3	I feel irritable all of the time, and don't know why.	Never Seldom Sometimes Frequently Always
4	I am bored with life in general.	Never Seldom Sometimes Frequently Always
5	Deep down I am dissatisfied and I don't know why.	Never Seldom Sometimes Frequently Always
6	I have trouble concentrating on my work.	Never Seldom Sometimes Frequently Always
7	It is difficult for me to make decisions.	Never Seldom Sometimes Frequently Always
8	I overreact to things at home and at work.	Never Seldom Sometimes Frequently Always
9	I can't seem to get organized.	Never Seldom Sometimes Frequently Always
0	I spend nights awake, or it takes forever to fall asleep.	Never Seldom Sometimes Frequently Always
1	I can't tell anyone how I feel.	Never Seldom Sometimes Frequently Always
2	My emotions get out of control.	Never Seldom Sometimes Frequently Always

Nutritional Assessment
	I eat a good breakfast (cereal, toast, fruit, milk, etc.)	almost always usually sometimes rarely
2	I have coffee and donuts/sweetrolls for breakfast. I don't eat breakfast	Never sometimes frequently most of the time
3	I usually eat the following types of foods.	mostly fresh or unprocessed, baked or steamed broiled, steamed, micro waved baked, canned, frozen fried, boiled, canned, prepared
4	My meal pattern is	eat 3 'average' meals daily or eat small frequent meals eat a lot of food and often skip some meals and eat a few medium to large ones skip many meals but eat a few large ones
5	Snack and dessert foods such as soft drinks, candy, pastry, sweetened breakfast cereal, and potato chips are in my diet.	rarely or Never only a few times a week almost daily at least once each day
6	My consumption of vegetables would be best described as:	several daily vegetables, fresh or frozen. almost every day some fresh, canned or frozen. three times a week canned, creamed, like in TV dinners. I hate vegtables.
7	Of the protein group, I eat	much vegetable protein, some fish and poultry, occasional meat and eggs occasionally red meat and eggs, primarily fish and poultry regularly every kind of meat, sometimes fried red meat, eggs and often
8	My intake of breads and grains would best be described as:	mostly whole grain, regularly and abundantly some whole grain, much white bread and pastas usually white bread, instant potatoes, crackers don't eat grains and cereals
9	The following identifies my consumption of fats (nut, oils, bacon, dressings, gravies, margarine, butter, fried foods, etc.)	My low intake of fat is primarily from cold-pressed vegetable oils and nuts. I restrict my fat intake I like these foods, eat them sometimes I love these foods, eat them often.
10	The following identifies my consumption of dairy products: I don't use dairy products	I eat nonfat milk, nonfat yogurt frequently with rare consumption of butter, cheese and regular ice cream. I use low fat milk, Regular yogurt, or cottage cheese, and very little consumption of cheese and ice cream. I mix my intake of low and regular diary products. I Love cheese, whole milk, butter, and ice cream!
11	The following foods are in my diet-fresh fruits, steamed vegetables, whole grains, and legumes (beans).	each of them daily, or nearly so several times each week sometimes rarely
12	The following identifies my consumption of fruits:	mostly fresh fruit, abundant and daily some fresh fruit, canned or dried, 4 times weekly some fresh fruit, canned or dried, 2 times weekly rarely

Exercise Level
1	How many times a week do you do an aerobic exercise for at least 20-30 minutes duration?	5-7 times per week Sometimes 2-4 times per week Once per week none
2	How may times a week do you participate in light exercises or sport activities?	5-7 times per week Sometimes 2-4 times per week Once per week none
3	How often do you do strength-building exercises-such as sit-ups, push-ups, using weight training equipment?	5-7 times per week Sometimes 2-4 times per week Once per week don't do them
4	How often to you do stretching exercises to improve the flexibility of your neck, shoulders, back, and leg muscles?	5-7 times per week Sometimes 2-4 times per week Once per week don't do them

Personal Health Information
Part I
Medical History:	I have no family history of heart disease or diabetes I have a family history of heart disease and/or diabetes I have heart disease
Blood Pressure Don't Know	Normal, 120/70 or less Upper normal, (121-139/71-89) Moderately elevated, (140-159/90-99) High, 160/100 or higher
Cholesterol Don't Know	Below 180 181-200 201-250 251 & Up
Part II
Family History	I have no family history of cancer I have a family history of cancer I (have) (had) cancer
Part III
Personal History
Alcohol (a drink is 4 ounces of wine, 12 ounces of beer, or 1.5 ounces of alcohol)	I do not drink alcoholic beverages I average no more that 2 drinks per day I average more that 2 drinks per day I stopped drinking but drank heavy for years
Tobacco	I do not use tobacco I stopped smoking less than two years ago I smoke less than 10 cigarettes a day I smoke more than 10 cigarettes a day

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