BACK Stress Resilience 13 Aug, 2020 Welcome to your Stress Resilience Name Email Phone SECTION 1Stress management How stressed do you feel daily?Not at allA littleQuite a lotDebilitating amountHave you had any major personal, family, work or relationship stresses recently?NeverRarelyOccasionallyDailyYOUR REACTION TO STRESS Listed here and on the next pages are some common ways of coping with stressful events. Mark those that most closely represent your behaviour or that you feel you use on a regular basis.I ignore my own needs and just work more.NeverRarelyOccasionallyDailyI seek out friends or therapists for support.DailyOccasionallyRarelyNeverI eat much more than usual.NeverRarelyOccasionallyDailyPainful and/or lumpy breasts?NoSometimesRegularlyDebilitatingCyclical headaches?NoSometimesRegularlyDebilitatingInfertility?NoI don´t knowRegularlyDebilitatingI engage in some type of physical exercise.DailyOccasionallyRarelyNeverI get irritable and take it out on those around me.NeverRarelyOccasionallyDailyI take a little time to relax, breathe and unwind.DailyOccasionallyRarelyNeverI smoke a cigarette or drink a caffeinated beverage.NeverRarelyOccasionallyDailyI confront my source of stress and work to change it.DailyOccasionallyRarelyNeverI withdraw emotionally.NeverRarelyOccasionallyDailyI change my outlook on the problem and put it in a better perspective.DailyOccasionallyRarelyNeverI sleep more than I really need to.NeverRarelyOccasionallyDailyI take some time off and get away from my work or the situation.DailyOccasionallyRarelyNeverI go out shopping and buy something to feel good.NeverRarelyOccasionallyDailyI joke with my friends and use humour to feel better.DailyOccasionallyRarelyNeverI drink more alcohol than usual.NeverRarelyOccasionallyDailyWeight Information Are you happy with your weightYesSomewhatNoVery unhappyI get involved in a hobby or interest that helps me unwind.DailyOccasionallyRarelyNeverI take medicine to help me relax or sleep better.NeverRarelyOccasionallyDailyI maintain a healthy diet.DailyOccasionallyRarelyNeverI just ignore the problem and hope it will go away.NeverRarelyOccasionallyDailyAbout YouYour new question!How many times a day do you eat pasta, rice, pastries, croissants, cakes, biscuits, pizzas, bread, cereals, rolls?NoneOneTwoMore than 2I pray, meditate, or enhance my spiritual life.DailyOccasionallyRarelyNeverI worry about the problem but do nothing.NeverRarelyOccasionallyDailyI try to focus on the things I can control and accept the things I can’t.DailyOccasionallyRarelyNeverSECTION 2 FOOD CHOICE (Please answer the questions below and on the following pages as accurately as possible) How many caffeinated coffees do you drink each day?NoneOneTwoMore than 2How many cups of normal caffeinated tea do you drink each day?NoneOneTwoMore than 2How many cups of herbal tea do you drink each day?More than 2TwoOneNoneHow many hot chocolate or hot malted drinks do you have per day?NoneOneTwoMore than 2How many spoonfuls of sugar, honey or sweeteners do you add to your hot drinks?NoneOneTwoMore than 2How many Fizzy drinks, e.g. cola, fanta, sprite etc (Not fizzy water) do you have per week?NoneOneTwoMore than 2How many glasses of fruit juice do you have per day?NoneOneTwoMore than 2How many glasses of any kind of alcoholic beverage do you drink a week?NoneOneTwoMore than 2How many times a week do you eat commercial chocolate or confectionery?NoneOneTwoMore than 2How many times a day do you eat white rice, white pasta and white bread?NoneOneTwoMore than 2How many times a day do you eat pasta, rice, pastries, croissants, cakes, biscuits, pizzas, bread, cereals, rolls?NoneOneTwoMore than 2How many times per week do you eat deep-fried food?NoneOneTwoMore than 2How many pieces of fruit do you eat each day?More than 3TwoOneNoneDo you eat vegetables with each of your meals – how many servings per day?More than 3TwoOneNoneDo you eat some raw salad vegetables how many servings per day?More than 3TwoOneNoneHow many times per day do you eat dairy products, e.g. milk, butter, cheese, cream, yoghurt, ice cream, meals or desserts that contain milk products?More than 3TwoOneNoneDo you use salt in your cooking or add it to food?DailyOccasionallyRarelyNeverHow many times a week do you eat salty snacks e.g. peanuts, crisps, snack biscuits, etc?More than 3TwoOneNoneHow many bought microwave meals do you eat per week?More than 3TwoOneNoneHow often do you eat meals from fresh ingredients?NeverOccasionallyRarelyDailyDo you eat out a lot? If so, how many times per week?More than 3TwoOneNoneDo you frequently eat under stressful conditions or on the move?DailyOccasionallyRarelyNeverHow many times per week do you eat meat and fish?More than 3TwoOneNeverSECTION 3 Detoxification HEAD Headaches?NoSometimesRegularlyDebilitatingFaintness?NoSometimesRegularlyDebilitatingDizziness?NoSometimesRegularlyDebilitatingInsomnia?NoSometimesRegularlyDebilitatingNot at allNoSometimesRegularlyDebilitatingSome symptomsNoSometimesRegularlyDebilitatingRegular problemsNoSometimesRegularlyDebilitatingDebilitating situationNoSometimesRegularlyDebilitatingEYES Watery or itchy eyesNoSometimesRegularlyDebilitatingSwollen, reddened or sticky eyelids?NoSometimesRegularlyDebilitatingBags or dark circles under eyes?NoSometimesRegularlyDebilitatingBlurred or tunnel vision?NoSometimesRegularlyDebilitatingEARS Itchy ears?NoSometimesRegularlyDebilitatingEaraches, ear infections?NoSometimesRegularlyDebilitatingDrainage from ear?NoSometimesRegularlyDebilitatingRinging in ears, hearing loss?NoSometimesRegularlyDebilitatingNOSE Stuffy nose?NoSometimesRegularlyDebilitatingSinus problems?NoSometimesRegularlyDebilitatingHay fever?NoSometimesRegularlyDebilitatingSneezing attacks?NoSometimesRegularlyDebilitatingMOUTHNoSometimesRegularlyDebilitatingMOUTHChronic coughing?NoSometimesRegularlyDebilitatingTHROATNoSometimesRegularlyDebilitatingTHROATGagging, frequent need to clear throat?NoSometimesRegularlyDebilitatingSore throat, hoarseness, loss of voice?NoSometimesRegularlyDebilitatingSwollen or discoloured tongue, gums, lips?NoSometimesRegularlyDebilitatingCanker sores?NoSometimesRegularlyDebilitatingSKIN Acne?NoSometimesRegularlyDebilitatingHive, rashes, dry skin?NoSometimesRegularlyDebilitatingHair loss?NoSometimesRegularlyDebilitatingFlushing, hot flushes?NoSometimesRegularlyDebilitatingExcessive sweating?NoSometimesRegularlyDebilitatingHEART Chest pain?NoSometimesRegularlyDebilitatingIrregular or skipped heartbeat?NoSometimesRegularlyDebilitatingRapid or pounding heartbeat?NoSometimesRegularlyDebilitatingLUNGS Chest congestion?NoSometimesRegularlyDebilitatingAsthma, bronchitis?NoSometimesRegularlyDebilitatingDifficulty breathing?NoSometimesRegularlyDebilitatingDIGESTIVE TRACT Nausea, vomiting?NoSometimesRegularlyDebilitatingDiarrhea?NoSometimesRegularlyDebilitatingConstipation?NoSometimesRegularlyDebilitatingBloated feeling?NoSometimesRegularlyDebilitatingHormone Balance Test For Men SYMPTOM GROUP 1 Weight loss?NoSometimesRegularlyDebilitatingShortness of breath?NoSometimesRegularlyDebilitatingHave you always been overweight?NoSomewhatYes as an adultAll my lifeIntestinal / stomach pain?NoSometimesRegularlyDebilitatingJOINTS/MUSCLE Pain or aches in joints?NoSometimesRegularlyDebilitatingArthritis?NoSometimesRegularlyDebilitatingHeightWeightBelching, passing gas?NoSometimesRegularlyDebilitatingHeartburn?NoSometimesRegularlyDebilitatingStiffness or limitation of movement?NoSometimesRegularlyDebilitatingFeeling of weakness or tiredness?NoSometimesRegularlyDebilitatingPain or aches in muscles?NoSometimesRegularlyDebilitatingWEIGHT Binge eating/drinking?NoSometimesRegularlyDebilitatingCraving certain foods?NoSometimesRegularlyDebilitatingExcess weight?NoSometimesRegularlyDebilitatingWater retention?NoSometimesRegularlyDebilitatingUnderweight?NoSometimesRegularlyDebilitatingCompulsive eating?NoSometimesRegularlyDebilitatingENERGY/ ACTIVITY Fatigue, sluggishness?NoSometimesRegularlyDebilitatingApathy, lethargy?NoSometimesRegularlyDebilitatingHyperactivity?NoSometimesRegularlyDebilitatingRestlessness?NoSometimesRegularlyDebilitatingMIND Poor memory?NoSometimesRegularlyDebilitatingConfusion, poor comprehension?NoSometimesRegularlyDebilitatingDifficulty in making decisions?NoeSometimesRegularlyDebilitatingStuttering or stammering?NoSometimesRegularlyDebilitatingSlurred speech?NoSometimesRegularlyDebilitatingLearning disabilities?NoSometimesRegularlyDebilitatingPoor concentration?NoSometimesRegularlyDebilitatingPoor physical coordination?NoSometimesRegularlyDebilitatingEMOTIONS Mood swings?NoSometimesRegularlyDebilitatingAnxiety, fear, nervousness?NoSometimesRegularlyDebilitaingAnger, irritability, aggressiveness?NoSometimesRegularlyDebilitatingDepression?NoSometimesRegularlyDebilitatingEnergy?NoneLowMediumHighOTHERFrequent illness?NoSometimesRegularlyDebilitatingFrequent or urgent urination?NoSometimesRegularlyDebilitatingGenital itch or discharge?NoSometimesRegularlyDebilitatingRegular colds and infections?NoSometimesRegularlyDebilitatingFrequent bouts of depression?NoSometimesRegularlyDebilitatingADDITIONAL WEIGHT INFORMATION Are you happy with your weight?YesSomewhatNoVery unhappyHave you always been overweight?NoSomewhatYes as an adultAll my lifeHow do you feel about your weight?ComfortableConcernedWorriedFrustratedHow have you felt about your weight in the past?Never an issueSometimes an issueOften a worryAlways an issueAre you prepared to reshape your lifestyle to achieve your health and weight goals...?Don’t want to changeWill look at small changesReady to make some changesTotally committed to do whatever I need toHow old are you?Under 3030-4546-5960+HeightWeight WeightTime is Up!