Lifestyle Questionnaire
These questions will give me a better understanding of who you are, leading to a deeper therapeutic relationship and allow us to reach our shared goals. Please do not feel pressured to answer any of the questions and it is totally fine if you would rather not share.
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Email *
Name and Age *
What is your marital status?
How many children do you have?
What are your main health concerns?
Which of the following are you doing for your health at the moment?
What do you beleive might be the causes or underlying factors of your current health concerns?
Have you expereinced trauma or loss in the past? If so, please provide a brief description if you are comfortable doing so. It is okay to leave this blank if you do not feel comfortable sharing.
What level of stress are you experiencing during this time in your life?
Clear selection
What are the major causes of stress in your life?
How does your stress manifest in your life? For example, increased pain, headaches, difficulty sleeping, increased fighting with family and friends, ect.
Do you utilize any coping mechanisms for your stress?
Clear selection
How many hours do you sleep daily on average?
On average, what time do you go to sleep?
On average, What time do you wake up?
Do you wake up feeling rested?
Clear selection
Are you satisfied with your energy levels? If not, how long have you felt like your energy levels have been lower then you would like.
What is, or was your occupation?
How many hours do you work each day?
Do you enjoy your work?
Clear selection
Do you smoke cigarettes regularly?
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If you do smoke cigarettes, how many do you smoke on average each day?
How many hours do you spend daily, on average...
0-1 hours
1-2 hours
2-3 hours
3-4 hours
4-5 hours
5-6 hours
6-7 hours
Column 8
Watching TV
On Social Media
Using Your Computer
Doing hobbies or activities that you love
Do you exercise? If so, what do you typically do?
How frequently do you exercise?
What are your interests and hobbies?
Do you take vacations regularly?
When was your last vacation?
Do you participate in church or other spiritual activities?
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How tall are you?
How much do you weigh?
Do you wish to gain or lose weight?
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How much weight would you like to gain or lose?
On average, How many times per day do you eat?
Do you snack throughout the day?
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On average, Do you eat meals...
At what time do you have your last meal or snack of the day?
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Do you eat or use any of the following products?
Please indicate how many cups of the following you drink per day.
0 cups
1 cup
2 cups
3+ cups
Caffeinated Tea
Fruit Juice
Vegetable Juice
Animal Milk
Soft Drinks
Row 11
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Are you a...
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How often do you eat meat?
How often do you consume dairy products?
What are your favorite foods?
Do you experience any symptoms if you miss a meal? If so, what?
Do you experience any symptoms after eating? If so, please describe.
Are there any foods that you avoid? If yes, why?
What are the goals you aspire to achieve for the next 12 months? *
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