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General Health Self-Evaluation
H U M
A N E X C E L L
E N C E
Name
_________________________________ Occupation ____________________
Address _______________________________ Phone # Day
___________________
City ______________________ ZIP _________ Eve.
____________________
Fax ________________ E-mail ________________ Today’s Date
_________
How did you
hear about my seminars, services or me? Radio ___________
Publication _______________ Store ________________
Friend _____________
Other __________________________________
1)
Rate yourself from 1-5 (1 being a no, 3 some times and 5
yes)
|
1 |
2 |
3 |
4 |
5 |
|
|
q |
q |
q |
q |
q |
I am happy with the way my body looks
to me. |
|
q |
q |
q |
q |
q |
I clearly understand how and when to
exercise, for the results I desire. |
|
q |
q |
q |
q |
q |
I have enough energy so I do not use
energy aids (i.e. caffeine,
herbs, nicotine, alcohol…). |
|
q |
q |
q |
q |
q |
I am currently at my healthy/unburdened
- body weight/body fat percentage. |
|
q |
q |
q |
q |
q |
I eat well and understand
healthy nutrition (shopping,
storing, preparation, presentation, digestion). |
|
q |
q |
q |
q |
q |
I find it easy to find, choose and
eat the "right" foods. |
|
q |
q |
q |
q |
q |
I have a clear understanding of what
foods my body needs to stay healthy. |
|
q |
q |
q |
q |
q |
I rarely get sick and have no
chronic diseases. |
|
q |
q |
q |
q |
q |
I take little or no medications.
(pain medications, digestive
aids, bowel transit aids…) |
|
q |
q |
q |
q |
q |
I have no body aches or pains. |
|
q |
q |
q |
q |
q |
I have great and healthy love for my
body and it shows. |
|
q |
q |
q |
q |
q |
I effectively listen to and understand
all that my body communicates to me. |
|
q |
q |
q |
q |
q |
I continually educate myself on
health, nutrition and fitness. |
|
q |
q |
q |
q |
q |
I have healthy and supportive social
structures and relationships. |
|
q |
q |
q |
q |
q |
I have a wide variety of healthy
health care professionals to guide/support me. |
|
q |
q |
q |
q |
q |
I do know how to solve all my body
problems/challenges. |
|
q |
q |
q |
q |
q |
I use several/many methods to monitor
my health. |
|
q |
q |
q |
q |
q |
I have a personalized health
maintenance program (process,
systems, plans, and actions). |
|
q |
q |
q |
q |
q |
I have clearly defined fitness and
health goals, and I am reaching them. |
|
q |
q |
q |
q |
q |
I am fit* enough to do more
than the things I want to do.
*fit = strength + flexibility +
endurance + balance
+ skill |
_____ Total Score
(top score possible 100)
2)
Right now I feel that these (from
above) are the three most important areas of my health for me
to
resolve/transform:
1 ________
___________________________________________________________________
2
________
___________________________________________________________________
3
________
___________________________________________________________________
3)
The reason these are important to me
now is because I would like to see and feel these results:
______________________ _________________________
________________________
______________________ _________________________
________________________
______________________ _________________________
________________________
4)
I feel these are the reasons I have not
yet achieved my desired results:
______________________ _________________________
________________________
______________________ _________________________
________________________
©1993-2001 Human
ExcellenceTM
Physical Health
Self-Evaluation
H U M
A N E X C E L L
E N C E
Please mark whether you may have had or are currently
having complications with:
| Area |
(P)ast or (Pr)esent |
Explanation / Description |
|
Joints |
___ |
____________________________________________ |
|
Tendons |
___ |
____________________________________________ |
|
Ligaments |
___ |
____________________________________________ |
|
Muscles |
___ |
____________________________________________ |
|
Bones |
___ |
____________________________________________ |
|
Organs |
___ |
____________________________________________ |
|
Lungs |
___ |
____________________________________________ |
|
Nervous system |
___ |
____________________________________________ |
|
External tissues |
___ |
____________________________________________ |
|
Heart (i.e. Angina, attack...) |
___ |
____________________________________________ |
|
Obesity |
___ |
____________________________________________ |
|
Stroke |
___ |
____________________________________________ |
|
Smoking |
___ |
____________________________________________ |
|
Drug abuse |
___ |
____________________________________________ |
|
Medications |
___ |
____________________________________________ |
|
High cholesterol |
___ |
____________________________________________ |
|
Arthritis |
___ |
____________________________________________ |
|
High blood pressure |
___ |
____________________________________________ |
|
|
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Do you have any family history of the above complications? (list)
______________________
_______________________________________________________________________
Has a health care provider ever told
you not to exercise? (When, Why)
_______________________________________________________________________
Do you or have you had difficulty
with physical exercise? ____________________________
Do you have any chronic or temporary
illnesses not listed above? (list)
_______________________________________________________________________
Do you have any back or joint
disorders that may be aggravated through exercising?
_______________________________________________________________________
Have you had surgeries performed?
(list) _______________________________________
Do you have any trouble sleeping and
getting fully rested? __________________________
To the best of my knowledge I
_______________ have listed and explained fully any and all, current and
past physical complications.
Date ___/___/___ Additional
information attached (circle) - Yes or No
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