To Rate Your Wellness, please answer each question using the scale below and select the "Submit" button at the bottom of this page. 0 – POOR      1 - FAIR      2 - GOOD      3 - VERY GOOD 1. My overall dietary and nutritional habits are 0   1   2   3 2. I take recommended individualized nutritional supplements daily 0   1   2   3 3. I avoid most of the time: sugar, dairy, alcohol, caffeine, red meat and fast foods 0   1   2   3 4. I eat whole organic foods most of the time 0   1   2   3 5. My energy level is 0   1   2   3 6. Physically I feel good with no pain or tension in my body 0   1   2   3 7. I have little stress and little worries 0   1   2   3 8. My bowel function is good; I eliminate 2 xs per day 0   1   2   3 9. The water that I shower, bathe, and drink, is filtered? 0   1   2   3 10. I sleep soundly 0   1   2   3 11. My cholesterol, LDL’s, triglycerides screenings are in normal range 0   1   2   3 12. I would rate my overall life style as ? 0   1   2   3 13. I exercise at 3-4 xs per week for at least 20 minutes? 0   1   2   3 14. Emotionally my thoughts are positive and I have a positive outlook? 0   1   2   3 15. My mental focus, concentration, and memory are? 0   1   2   3 16. Do I have non toxic fillings and healthy gums? 0   1   2   3 17. I check my breasts (female) or prostate (male) monthly for changes 0   1   2   3 18. I put my health first * before anything else? 0   1   2   3 19. I am happy with my job and my family life? 0   1   2   3 20. I do not take any pharmeuctical drugs unless it is only short term 0   1   2   3 21. I stay connected to God and or nature 0   1   2   3 22. My working or home environment is a healthy environment? 0   1   2   3 23. I maintain a healthy weight 0   1   2   3 24. I do see a Wellness Preventive Doctor 0   1   2   3 25. I visit an MD for a routine physical 0   1   2   3 This AHA document is not to be used and copied without legal permission. 847-955-0800. DrGailND@alternativehealthassoc.com.