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Lifestyle Medicine Assessment

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Lifestyle Medicine Assessment

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American Academy of Family Physicians

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For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Felt your life had a sense of purpose

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Used olive oil as your primary oil or used no oil when cooking

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Engaged in two or more spiritual or religious practices (e.g., meditation, prayer, church services, etc.)

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Felt that you were able to manage and deal with stressors effectively most days

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Interacted with one or more club(s) or organization(s) (e.g., athletic, community, school group, etc.)

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Smoked, vaped, or used tobacco/e-cigarette

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Visited or spoke to a close friend or family member on three or more separate occasions

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Woke up feeling refreshed and rested on most days

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Spent at least two hours in nature (approximately 20 minutes daily)

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…

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Felt you had enough time to take care of yourself most days

Yes

Correct Answer

Enter Points

No

Correct Answer

Enter Points

For each item, think about the last seven days and provide your best estimate for each:

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Enter any additional information about the quiz.

	less than 1	1	2	3	4	5	6	7	8	9	10+
Total number of sit-down or take-out restaurant meals
Total number of resistance training workouts performed(e.g., pushups, squats, pullups, etc.)
Total number of sweetened drinks consumed(e.g., juice, sweetened coffee or tea, soda, sports drinks, etc.)
Highest number of alcoholic drinks consumed on any single day
Average number of packaged snacks per day(e.g., chips, crackers, cookies, candy, protein bars, etc.)
Average number of hours slept per night
Average number of daily servings of fruit
Average number of hours spent sitting each day
Average number of alcoholic drinks consumed on days alcohol wasconsumed (select less than one if you did not drink any alcohol)
Average number of daily servings of vegetables

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Enter any additional information about the quiz.

	less than 30 minutes	30 minutes	45 minutes	1 hour	1.5 hour	2 hour	2.5 hour	3 hour	3.5 hour	4 hour	4.5 hour	5 or more hours
Total amount of cardiorespiratory exercise during the week (e.g., brisk walk, jog, etc.)

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You got a score of %%YOURSCORE%% out of %%TOTALSCORE%%

This is an opportune time to
work with your provider to
help you adopt habits that
will significantly improve
your health.

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This is an opportune time to work with your provider to help you adopt habits that will significantly improve your health.

Continue

You got a score of %%YOURSCORE%% out of %%TOTALSCORE%%

You have some great health
habits, though there is ample
opportunity to improve your
health and decrease your
disease risk.

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You have some great health habits, though there is ample opportunity to improve your health and decrease your disease risk.

Continue

You got a score of %%YOURSCORE%% out of %%TOTALSCORE%%

You have many healthy
habits, though there are a few
areas that you should assess
your habits in to see if you
can improve them.

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You have many healthy habits, though there are a few areas that you should assess your habits in to see if you can improve them.

Continue

You got a score of %%YOURSCORE%% out of %%TOTALSCORE%%

You’re doing great, though
there are a few minor tweaks
to your lifestyle, you can
make that will lead to better
overall health.

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You’re doing great, though there are a few minor tweaks to your lifestyle you can make that will lead to better overall health.

Continue

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*Dr. Nicolle’s blog and website provides general health information for educational purposes only. This information is not to be used as a substitute for medical advice, cannot diagnose or treat any health condition, and does not substitute for care from your own physician.

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Omega Integrative Healthcare, LLC

925B Peachtree St, NE, #500

Atlanta, GA 30309

(678) 948-5288