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The Quality of Life Assessment Survey is free of charge and may help you better determine if our services would be beneficial to you and your family.
Please respond to the following statements by clicking on the circle adjacent to the response that describes you most accurately. When finished click the Calculate Score button to receive your assessment.
your first name: |
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| I feel the direction my health is going is out of my control. |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I have a lot of stress in my life. |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I rarely drink 10-8 oz. glasses of good water every day: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I use tobacco: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I use recreational drugs: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I have debilitating allergies: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| My diet contains a lot of sugar: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I can’t find the time or desire to exercise with any regularity: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I consume a minimal or moderate amount of alcohol: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I have been exposed to serious toxins: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I have had a high number of major infections in my life: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| My body weight is higher than I would like: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I can’t seem to lose the extra weight I am carrying: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I crave sugar or sweets too frequently: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I have difficulty falling asleep at night: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I wake up tired and groggy in the morning: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I need caffeine (coffee, tea, soda) or sugar to get going in the morning: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I seem to get sick more frequently than others I know: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I worry about my health more than I would like to: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| If there is a cold or flu going around, I almost always catch it: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| When I get a cold or the flu, I recover slowly: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| When I recover from a cold or flu, I frequently have a relapse: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| When I get emotionally upset, I can’t seem to let it go easily: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I don’t seem to have enough energy to do everything I want to do: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I feel like my body is aging faster than normal: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| My occupation is not fulfilling: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I feel the areas of my life (career, recreation, family, friends) are out of balance: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I find it difficult to feel peaceful and relaxed: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I am not as healthy as I could be: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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| I feel restricted physically from doing the things I want to do: |
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
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