Health & Wellness Self-Test Interactive Form

Internal Medicine & Pediatrics | Wellness Test

Green Zone: 81-100% - Good Health & Wellness

Yellow Zone: 51-80% - Average Health & Wellness with some room for improvement

Red Zone: 0-50% - Poor Health & Wellness

Nutritional Health & Wellness

1) How many servings of fruits do you eat in one day? One serving is equal to the size of your fist, or one cup of chopped or sliced fruits, or one medium sized fruit.

0
1-2
3 or more

2) How many servings of vegetables do you eat in one day? One serving is equal to the size of your fist, or one cup of chopped or sliced vegetables.

0
1-2
3 or more

3) How many servings of milk, cheese, yogurt or other dairy products do you eat in one day? One serving is equal to four cheese dices or 1 cup of milk or yogurt. If you do not eat dairy, how many calcium fortified foods did you eat?

0
1-2
3 or more

4) How many servings of bread, cereal, pasta or other grains do you eat in one day? One serving is equal to one slice of bread or ½ cup of boiled pasta, rice, or noodles or 1 cup of plantain.

0-2
3-5
6 or more

5) How many of the bread, cereal, pasta or grains servings in a day was listed (on the label) as 100% whole grain or 100% whole wheat products?

0
1-2
3 or more

6) How many servings of soft drinks, deserts, candy, cookies, or any sugary treats or snacks do you eat in one day? One serving is equal to a small candy bar, one cup of soft drink, 1 cookie, or ½ can of soda.

0
1-2
3 or more

7) How many servings of meat, poultry, fish, eggs, beans or nuts do you eat in one day? One serving is equal to 3 ounces of meat, one egg, ½ cup of dry beans or 2 ounces of nuts.

0-1
2
3 or more

8) How many of the meat, poultry, or fish that you eat in a day were fatty meats like bacon, sausage, or processed lunchmeats? One serving is 3 slices of bacon, sausages, 1 slice of lunchmeat.

0
1-2
3 or more

9) How many servings of deep fried (meaning covered in batter and fried in oil) foods such as French fries, onion rings, fried chicken or fish, do you eat in a day?

0
1-2
3 or more

10) In 24 hours, the average person should eat 3 portioned meals and 2 portioned snacks. Based on this information, on average, do you…

I do not eat very much. I am hungry all day.
I eat the right amount. I am rarely over stuffed and rarely hungry.
I eat more than I should because I added more portions to my meals or snacks.

Physical Wellness & Fitness

1) How often in a week, do you exercise for at least 30 minutes a day?

Rarely Ever
1-3 times a week but for less than 30 minutes
5 times a week.

2) How many hours of stationary activity (watching TV, playing video games, or using the computer) do you do in a day?

0
1-2
3 or more

3) How long can you maintain your body straight on the ground like a plank (push up position without going down)?

1 to 30 seconds
31 to 60 seconds
61 seconds or above

4) How many complete push-ups can you do in a minute?

1 to 5
6 to 15
16 and up

5) How long does it take you to run a mile?

12 minutes and up
9:01 to 11:59
Less than 9 minutes

6) How far can you go on the sit-and-reach test?

Can't get my fingertips past my kneecaps
Can't get my fingertips to my toes
I can grab my toes.

7) How long can you hold a wall sit (they suck, we know)?

0 to 30 seconds
31 to 59 seconds
1 minute and up

8) What is your BMI? (Calculate your BMI)

Over 25
18.5 to 24.9
Under 18.5

9) How long can you maintain 100 rpm on a stationary bike?

0 to 1 minutes
2 to 4 minutes
5 minutes or above

10) How active are you at work?

Very inactive, I sit at a desk all day
Somewhat active, I walk occasionally up and down the stairs for exercise or I take short walks during coffee breaks
Very active, I am walking or moving most of the day

Emotional Wellness

1) How Much Sleep Do You Get Per Night, Or Combined With Naps?

8 or more
6-7 hours
Less than 5 hours

2) How often do you have conflict with others?

Hardly ever because I maintain boundaries and respect others needs
Sometimes, but I normally work things out.
A lot and sometimes friendships are lost or I tend to burn bridges.

3) For the past 2 weeks, I've been feeling depressed, down, or hopeless.

Strongly Agree
Sometimes
Strongly Disagree

4) I tend to think rationally and optimistically.

Strongly Agree
Sometimes
Strongly Disagree

5) I refuse to allow regrets and disappointments cloud "today".

Strongly Agree
Sometimes
Strongly Disagree

6) I feel a great sense of control over my emotions, thoughts and feelings.

Strongly Agree
Sometimes
Strongly Disagree

7) I have a healthy sense of humor and I don't mind laughing at life's imperfections.

Strongly Agree
Sometimes
Strongly Disagree

8) I feel more gratitude on how my life is now rather than focus on what's lacking

Strongly Agree
Sometimes
Strongly Disagree

9) I feel satisfied with who I am and where I am in my life.

Strongly Agree
Sometimes
Strongly Disagree

10) For the past 2 weeks, I've had little interest or pleasure in doing things.

Strongly Agree
Sometimes
Strongly Disagree

Mental Wellness

1) How Clean Is Your House?

My home is clutter-free and relaxing
I have a little clutter here and there but usually clean up when someone is coming over
I avoid coming home because it's so messy

2) At the end of the day, do you…

Relax in a tub before going to bed and reflect on your day
Avoid others because you are sick of talking to everyone
Drink excess alcohol or use prescription or non prescription drugs to help relax

3) What do you do on your days off?

Travel or sports, or go out to movies or dinner, or any fun activity
Run errands to catch up on what I haven't done because of work
Rest because I'm too tired to do much

4) How Are You With Time Management?

Great. I'm always on time or early to appointments.
Okay. I'm somewhat disorganized with time and occasionally I'm late to appointments
Not Great. I could use some help with time management and I'm always late to appointments.

5) How Organized Are You?

Very. I have a place for everything.
Somewhat. Sometimes I have to scramble to find things, and I don't always find them.
Not Very. I frequently misplace things and regularly pay bills late, miss appointments or never find things because I'm disorganized.

6) For the past 2 weeks, how often have you felt like a failure or that you let your family down?

Every day
Some days during the week
Not at all

7) For the past 2 weeks, how often have you had a poor appetite or overeating

Every day
Some days during the week
Not at all

8) For the past 2 weeks, how often have you had trouble falling asleep or have you been sleeping too much?

Every day
Some days during the week
Not at all

9) For the past 2 weeks, how often have you felt tired or with little energy?

Every day
Some days during the week
Not at all

10) For the past 2 weeks, how often have you had trouble concentrating on things such as reading or watching TV?

Every day
Some days during the week
Not at all

Social & Occupational & Spiritual Wellness

1) Do You Feel Good About What You Do For a Living?

Yes, it really fulfills me.
Mostly but sometimes I get bored or frustrated
Not at all, I hate going to work but it pays the bills.

2) How Balanced Is Your Lifestyle?

Balanced. My typical week includes a manageable amount of responsibilities, a good amount of time with loved ones, and some personal time for myself.
A Little Imbalanced. My typical week includes a little too much responsibility and not enough time with loved ones or time for myself.
Imbalanced. I carry too much responsibility and have almost no time to relax with loved ones or spend on myself.

3) If you win a million dollar tomorrow, would you…

Quit immediately tomorrow
Cut down on the amount of hours that you work
Keep working the same amount of time on your job because you absolutely love what you do

4) Do You Have Anyone To Talk To About The Things In Your Life That Upset Or Stress You?

Yes, I have a very supportive network of people
Yes, I have 1-2 friend that I can talk to if I really need to talk.
No, I really have no one to talk to about my feelings at all.

5) How's Your Sex Life?

Great! I couldn't ask for anything better!
Pretty Good. I wish it were a little more satisfying, but overall I can't complain.
Not Great. There are some major things I'd like to change (frequency, satisfaction, more desire, etc.), but it could be worse.

6) What Is Your Financial Situation Like?

Great. I have savings, and a great credit rating.
Okay. I have little or no money in savings, and my credit score could be higher.
Bad. I don't have any savings, and I am in debt.

7) I feel a strong sense of connection with others and do not feel isolated.

Strongly Agree
Sometimes
Strongly Disagree

8) I have made real personal sacrifices in order to make the world a better place, like trying to prevent war, poverty and injustice.

Strongly Agree
Sometimes
Strongly Disagree

9) I often feel a strong spiritual or emotional connection with all the people around me.

Strongly Agree
Sometimes
Strongly Disagree

10) I love the blooming of flowers in the spring as much as seeing an old friend again.

Strongly Agree
Sometimes
Strongly Disagree

Internal Medicine & PediatricsDennar Medical & Wellness Solutions

CALL TODAY: (504) 361-4203

Internal Medicine & Pediatrics Dennar Medical & Wellness Solutions

CALL TODAY: (504) 361-4203

Health & Wellness Self-Test Interactive Form

Nutritional Health & Wellness

Physical Wellness & Fitness

Emotional Wellness

Mental Wellness

PCMC Blog

Internal Medicine & PediatricsDennar Medical & Wellness Solutions

CALL TODAY: (504) 361-4203

Internal Medicine & Pediatrics Dennar Medical & Wellness Solutions

CALL TODAY: (504) 361-4203

Health & Wellness Self-Test Interactive Form

Nutritional Health & Wellness

Physical Wellness & Fitness

Emotional Wellness

Mental Wellness

Social & Occupational & Spiritual Wellness

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PCMC Blog