1.
How often do you brush and floss your teeth? a) Twice daily b) Once a day c) I don’t brush and floss regularly.
2.
Do you fall asleep easily and sleep through the night? a) Most of the time b) Occasionally c) Rarely
3.
How many hours of sleep do you get a night? a) Less than five hours b) Between six and nine hours c) More than nine hours
4.
How many eight-ounce glasses of water do you drink daily? a) 0-3 b) 3-6 c) 6-9 d) Ten or more
5.
The main source of the water you drink is: a) Municipal b) Home well or stream c) Home carbon-filtered/reverse-osmosis d) Bottled or delivered e) Distilled f) Carbonated mineral water
6.
On a scale from 1-10 (1 being the lowest, 10 being the highest), how would you rate your overall energy level? a) 0-2 b) 3-5 c) 6-8 d) 9-10
7.
How often do you have a bowel movement? a) Less than once a day b) Once a day c) Two to three times a day d) More than three times per day
8.
Do you smoke or chew tobacco products? a) Never b) No, but I’m exposed to secondhand smoke. c) Occasionally d) Regularly e) Used to, but quit
9.
How often do you consume an alcoholic drink, e.g. a bottle of beer, a glass of wine, an ounce of hard liquor? a) Never b) Occasionally c) Regularly d) I’m a recovering alcoholic.
10.
Do you use recreational drugs? a) Never b) Occasionally c) Regularly d) Used to, but quit
11.
How many prescription medications do you regularly take? a) None b) 1-2 c) 3-5 d) Five or more
12.
Concerning your weight, do you consider yourself to be: a) Underweight b) Just right c) Overweight d) Obese
13.
Concerning any type of body pain, do you experience: a) Longstanding/chronic pain b) Recent/acute pain c) No pain most of the time
14.
Do you suffer from any chronic diseases? a) Yes, and it interferes with my daily life. b) Yes, but it does not interfere with my daily life. c) No
15.
I am satisfied with the frequency and quality of my sexual activity: a) Not applicable b) Rarely c) Occasionally d) Regularly
16.
I practice safe sex with only one partner: a) Rarely b) Occasionally c) Regularly d) Always
17.
Are you aware of your current blood pressure and cholesterol readings? a) Yes, and they are normal. b) Yes, and they are abnormal. c) No, I am not aware.
18.
When considering your immediate family -- grandparents, parents, and siblings -- how is their general health overall? a) Excellent b) Good c) Fair d) Poor e) Extremely poor
19.
Concerning your meals, most are: a) Takeout/fast food b) Restaurant food c) Packaged, frozen, canned food d) Fresh, unprocessed, home cooked
20.
How often do you eat processed, fast, or junk foods? a) Rarely b) Occasionally c) Regularly
21.
How often do you eat deep-fried, microwave, or packaged processed foods? a) Rarely b) Occasionally c) Regularly d) Frequently
22.
How often do you consume raw or lightly cooked vegetables? a) Rarely b) Occasionally c) One to two times daily d) Three to four times daily e) More than five times daily
23.
How often do you consume raw fruit? a) Rarely b) Occasionally c) One to two times daily d) Three or more times daily
24.
How often do you consume super foods such as sprouts, fresh-juiced drinks, or powdered green drinks? a) Never b) Rarely c) Occasionally d) Regularly
25.
How often do you eat beans/legumes such as black, pinto, kidney, or lentils? a) Rarely b) Occasionally c) Regularly
26.
How often do you consume unprocessed raw nuts and seeds? a) Rarely b) Occasionally c) Regularly
27.
How often do you consume beverages such as coffee, regular tea, pop, powdered/instant drinks, or sweetened fruit drinks? a) Rarely b) Occasionally c) Regularly d) Frequently
28.
What type of flour/grain products do you consume? a) Mostly white-flour products b) Mostly whole-wheat products c) Mostly rice d) Mostly alternative grains, e.g. spelt, millet, kamut, rye, oats, quinoa
29.
What types of oils do you use most often in your diet? a) Butter b) Margarine c) Lard d) Flax/fish oil e) Virgin olive oil f) Commercial vegetable oil g) Not sure
30.
What type of sugar or sweetener do you most commonly use? a) Sugar b) Artificial sweetener c) Honey d) Maple syrup
31.
On average, how often do you consume sugar/sweetener? a) Rarely b) Occasionally c) Regularly d) Frequently
32.
Concerning red meat, I mostly eat: a) Organically raised b) Wild c) Commercially raised d) Little or no red meat
33.
Concerning white meat, such as chicken, turkey, and pork, I mostly eat: a) Organically raised b) Commercially raised c) Little or no white meat
34.
Concerning fish, I mostly eat: a) Wild b) Commercially farmed c) Little or no fish
35.
I consider my salt consumption to be: a) Light b) Medium c) Heavy
36.
I do not skip meals and consider my diet to be balanced: a) Most of the time b) Some of the time c) Rarely
37.
I am aware of the seasonal availability of foods and eat in a varied and rotated manner: a) Most of the time b) Some of the time c) Rarely
38.
My understanding and knowledge of the amount and type of food additives, colorings, and preservatives I consume is: a) High b) Medium c) Low d) Not aware
39.
I take time to eat, chew my food well, and relax during my meals: a) Rarely b) Occasionally c) Regularly
40.
I use nutritional supplements/herbs: a) Rarely b) Occasionally c) Regularly
41.
I am aware of the safe intake levels for supplements/herbs and optimal consumption times: a) Yes b) Somewhat c) Not sure d) No
42.
How often do you fast or practice other detoxification methods? a) Rarely b) Occasionally c) Regularly
43.
How would you rate your overall level of physical fitness? a) Excellent b) Good c) Fair d) Poor
44.
Do you exercise: a) Year-round b) Seasonally c) Occasionally d) Rarely
45.
Please indicate how long you have been exercising on a regular basis: a) I do not exercise regularly. b) Less than six months c) Between six months and two years d) Over two years
46.
How long does a typical exercise session last for? a) Less than 10 minutes b) 10-20 minutes c) 21-30 minutes d) 31-60 minutes e) Over an hour
47.
How many days per week do you engage in continuous cardiovascular exercise for 20 minutes or more? a) 0 b) 1-3 c) 4-7
48.
On average, how would you rate your effort when performing your cardiovascular exercise? a) Little effort b) Moderate effort c) Maximum effort
49.
How many days per week do you participate in strength training exercises? a) 0-1 b) 2-4 c) 5-7
50.
How many days per week do you engage in exercises that promote flexibility, e.g., “stretch-and-hold” exercises, Tai Chi, Yoga? a) Never b) 1-3 c) 4-7
51.
Are you able to carry out your daily tasks -- e.g. laundry, vacuuming, grocery shopping, mowing the grass, house cleaning -- without feeling extremely overexerted or exhausted? a) Most of the time b) Occasionally c) Rarely
52.
How would you describe your activity level during the day? a) Not active b) Somewhat active c) Active d) Very active e) Labor intensive
53.
Is your primary residence located near any of the following: a major highway or street; an airport; heavy industry; a landfill or incinerator; an orchard or farm; high-tension wires or radio/telephone/radar antennas? a) None of the above b) One of the above c) Two of the above d) Three of the above e) Four of the above f) Five of the above g) All of the above
54.
Do any of the following descriptions apply to your home: it is more than 40 years old; it is new or newly renovated; it has an attached or underground garage; it has a moldy basement or windows; it has natural-gas appliances; it houses indoor pets? a) None of the above b) One of the above c) Two of the above d) Three of the above e) Four of the above f) Five of the above g) All of the above
55.
Do any of the following descriptions apply to your workplace: you experience significant exposure to chemicals, dust, fumes, noise, etc.; it has poor air quality; it is new or newly renovated? a) None of the above b) One of the above c) Two of the above d) All of the above
56.
How much fresh, open air and moderate sunshine exposure do you get? a) None b) Little c) Moderate d) Lots
57.
Does your occupation require shift work? a) Yes b) No c) Occasionally
58.
What is the total number of hours you drive your car, ride public transit, or fly per week? a) 0-3 b) 4-10 c) More than 11
59.
What is the number of combined hours per week that you use the computer, telephone, or television? a) 0-5 b) 6-15 c) 15-25 d) 30-60 e) More than 60
60.
I feel my life is balanced between work, rest, and play: a) Most of the time b) Some of the time c) Rarely
61.
I feel I have a healthy relationship with my food: a) Yes b) No c) Sometimes
62.
In appropriate situations I can be spontaneous: a) Regularly b) Occasionally c) Rarely d) Never
63.
I understand and know the need to play, and in my life I: a) Regularly play b) Occasionally play c) Rarely play d) Never play
64.
In the course of an average day, I laugh: a) Rarely b) Occasionally c) Regularly
65.
I use some form of relaxation, meditation, or prayer: a) Rarely b) Occasionally c) Regularly
66.
Do you have a spiritual practice or faith? a) Yes b) No c) Not sure
67.
I feel safe and secure in my home and neighborhood: a) Yes b) No
68.
I have people whom I am close to and with whom I can share my feelings: a) Rarely b) Occasionally c) Regularly
69.
I experience love and affection in my life: a) Rarely b) Occasionally c) Regularly
70.
Have you personally ever experienced or witnessed physical, sexual, verbal, or emotional abuse? a) Never b) Rarely c) Occasionally d) Regularly
71.
I have been able to understand, process, and release previous negative experiences: a) Yes b) No c) Unsure
72.
I experience the emotion of joy in my life: a) Rarely b) Occasionally c) Regularly
73.
Concerning stress, would you say your stress level is: a) High b) Medium c) Low
74.
When you encounter a stressful situation, do you: a) Capitulate/surrender b) Withdraw c) Compromise/work it out d) Refuse to compromise
75.
How often do you worry? a) Rarely b) Occasionally c) Frequently
76.
Our primary emotions include sadness, fear, anxiety, joy, and anger. On any given day, are you aware of these four emotions and able to process them/express them so that your suppression of them does not have a negative effect on your day? a) Rarely b) Occasionally c) Regularly d) Not sure
77.
I allow myself to cry when experiencing sadness: a) Never b) Occasionally c) Frequently d) Always
78.
Do you have a sense of feeling trapped and hopeless/scared in your life today? a) Yes b) No c) Sometimes
79.
Do you suffer from a mental illness, such as depression, chronic anxiety, bipolar disorder, schizophrenia, etc.? a) Yes b) No c) Not sure
80.
Of the following character/personality traits, which one most describes you? a) Driven/pressured to succeed b) Perfectionist/need control c) Stubborn/uncompromising d) Laid-back/relaxed e) Prioritize others' needs over one’s own f) Pessimistic/negative g) Optimistic/positive h) Highly motivated/empowered
I have experienced greater health than illness in my life: a) Yes b) No
82.
83.
84.
I see illness as a process that helps me change and grow: a) Yes b) No
Disclaimer: The information on this website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the research and experience of Wellness Factors.
Disclaimer: This self-test cannot diagnose any condition or tell you for certain if your symptoms are harming your health; rather, it is a screening test to determine the likelihood of problematic issues. You should see a professional for further evaluation.
