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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