My top 3 concerns today - Wellness Essentials, LLC
Name: _________________________________________________ Date: _____________
NOTE: This data is used for stress reduction only.
Every day I consume: Please circle item
Servings of fresh fruits ……………………………….5 or more 4 3 2 1 0
Servings of vegetables & salad …………………….. 5 or more 4 3 2 1 0
Servings of green foods………. …………………….. 5 or more 4 3 2 1 0
Servings of fried foods per day……………………….5 or more 4 3 2 1 0
Servings of nuts per day (2 oz or ¼ cup)……………5 or more 4 3 2 1 0
Number of bowel movements per day……………………………...4 3 2 1 0
Number of hours of sleep per night………………… 8 or more 7 6 5 4 3 2 1 0
Number of meals eaten per day…………………………………………………5 4 3 2 1 0
I usually have back pain this many times a day…………….7 6 5 4 3 2 1 never constant
I usually eat this for breakfast:____________________________________________________
I usually eat this for lunch :____________________________________________________
I usually eat this for supper :____________________________________________________
I usually eat these protein foods daily:______________________________________________
I usually eat these nuts daily between meals:________________________________________
I usually use the following oils when I cook: Coconut Olive Canola Vegetable Shortening
I usually eat the following: margarine or butter
I use the following to balance the flora in my gut: Acidophilus Kephir Yogurt
I use the following sweeteners: white sugar brown sugar splenda sweet-n-lo Honey Stevia Xylitol
I cook with the following cookware: Teflon aluminum stainless steel glass
I use the following deodorant:_______________________________________________________
I use the microwave to cook the following foods:________________________________________
List 4 high fiber foods you eat daily:__________________________________________________
I spend this amount of time on a cell phone monthly:_____________________________________
When I want a snack I reach for what?____________________________________________
I have the following cravings: Please circle item
*Salt (Adrenal) *Chocolate(Magnesium) *Peanut butter(B-complex) *Cheese(Calcium)
*Banana’s(Potassium) *Apples (pectin to lower cholesterol) *Nuts(B-vitamins/magnesium) *Pickles(Sodium)
*Eggs(Choline) *Milk(Calcium or tryoptophane) *Cantelope(Potassium) *Olives(Thyroid)
*Onions(lungs) *Tart fruits(Gallbladder) *Paint or dirt(Calcium or Vitamin D)
I often have some of the following symptoms: Please check boxes that apply.
( Staying focused on my job while working ( Don’t have much energy after working 8 hours
( Cold hands or feet ( Feel exhausted all the time
( Feel Dizzy upon standing ( My hair is falling out
( Legs jerk while sleeping ( Short term memory loss
( Have a hard time loosing weight ( Have indigestion or burning in stomach after eating
( I have dark circles under my eyes ( I am loosing my hair or my nails are brittle
( I crave salty foods ( Have hot flashes ( I crave chocolate
( Have gained weight around my waist line in the last year
( I have allergies (list) ____________________________________________________________________
I consider myself to have good health. ( yes ( no
I am this ready to make lifestyle changes to become healthier:
( Not at all ( I plan to make changes in next 6 months
( I plan to make changes in next 3 months ( I plan to make changes in next 30 days
Name: _________________________________________________ Date: _____________
In the past two weeks, I have felt: ( Down, depressed, or hopeless ( Good
( Little interest or pleasure in doing things ( Great
I have back pain: ( no ( yes, Explain: ___________________________________________
____________________________________________________________________________
I am coping with my stress level:
( Very well ( Well ( Some trouble ( Often trouble coping
( Can’t cope anymore ( Need help
I have had the health conditions I checked below:
( Heart attack ( High cholesterol ( Bypass surgery ( Stroke ( Asthma
( Heart failure ( High blood pressure ( Cancer ( Chronic pain_______(where)
( Lung disease ( Arthritis ( Depression ( Frequent headaches
( Diabetes: Type 1 or Type 2 (Age at onset ) I use insulin ___yes ___no
I have a brother, sister or parent with diabetes yes no
I gave birth to a baby weighing more than 9 #’s yes no
( Other major medical problems:_________ _________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Tobacco Use:
( Never ( Quit years ago Type of tobacco used __
( Current user: ( Cig. packs ( Cigar ( Pipe ( Chew. Packs per day ____# years____
Other
In the past four weeks I have experienced a persistent cough, chest tightness or heaviness, wheezing,
extreme fatigue and/or acute shortness of breath. Please circle which symptom(s).
( Never ( 2 times/week ( Daily ( Continually
In past four weeks I have been awakened at night by cough, chest tightness or heaviness, wheezing,
and/or shortness of breath. Please circle which symptom(s).
(Never ( under 4 times/month ( 1-2 times/week ( 3 times or more/week
Taking care of me
I do the following things to help manage my stress:__________________________________________
_______________________________________________________________________________________
I understand that Kari Uselman, Ph.D., biofeedback practitioner, non-medical doctor, is providing biofeedback and stress reduction. I agree that I am receiving suggestions to improve my health. It is my choice and responsibility to improve my health. These are only suggestions.
___________________________________ ______ _________________________
Signature Date
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