Health Satisfaction Questionnaire Form | Windmill Wellness Center

HEALTH SATISFACTION SCORE

This is a subjective survey that you complete reflecting how satisfied you are with your physical, chemical and emotional/mental health. Understanding these ratings and answers can help us to work together, as a team, to achieve your health & wellness goals.

Date

Name

First Last

Date of Birth

Email

Please answer the following questions on a scale of 1 to 10.
1 - represents that you DO NOT agree with the statement and
10 - representing that you ABSOLUTELY AGREE with the statement

PHYSICAL HEALTH

1. Are you presently using any prescription drugs?

2. I have a physically attractive body that I am proud to look at in the mirror

3. I have not had many physical traumas in my life (broken bones, sprains, accidents, bad falls, etc)

4. I get a minimum of seven hours of sleep nightly

5. I have been under chiropractic care within the past year

EMOTIONAL/MENTAL HEALTH

1. I am a calm, peaceful person. I can self-regulate my thoughts and feelings and focus my mind at will.

2. I practice some form of self-care and relaxation (prayer, meditation, breathing techniques, yoga, tai chi, etc.)

3. Most of the time, I am truly happy and feel a sense of purpose in my life

4. I have healthy relationships and a rich social network of family, friends and activities

5. I am organized. I have time for myself and I can prioritize the most important tasks in my life

6. I have not had many emotional traumas in my life (abuse, neglect, divorce, death, illness, etc.)

NUTRITIONAL/ CHEMICAL HEALTH

1. I eat 4-6 small meals daily (or follow an intermittent fasting schedule) and properly combine fats, proteins and carbs

2. I supplement everyday with high quality supplements, such as a vitamin/mineral complex, probiotic, antioxidants and good fatty acids.

3. I do not take medications for chronic medical problems such as, digestive disorders; cardiovascular problems; headaches; chronic pain; blood sugar problems; chronic fatigue; chronic infections; hormonal issues; immune concerns or any other chronic condition.

4. I do not smoke cigarettes, use vaping products or any other type of tobacco product

5. I drink water as my primary beverage and consume, at minimum, half my body weight in ounces of water per day.