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
 Cold hands or feet
 Don’t have much energy after working 8 hours
 Feel exhausted all the time
 Feel Dizzy upon standing
 Legs jerk while sleeping
 My hair is falling out
 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
 Can’t cope anymore
 Some trouble  Often trouble coping
 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