Clinical Assessment, I-DareToLive

Name *

First

Last

Address Line 1 *

Address Line 2

Country *

Zip Code *

What kind of area do you live in?

Telephone Number - Mobile

Email *

Gender *

Male
Female

Date of Birth (mm/dd/yr) *

Age *

Employment: Job Title/Studying: Educational Level and Program of Study. *

Describe your job requirements, daily home activities, or study activities. *

Employer/Educational Institution

Work/School Address

Work/School Telephone

Briefly describe your psychological (individual and/or family) and/or health challenges: *

NOTE: As you complete the rest of this form, you may encounter a follow-up question that does not apply to you. If so, kindly state "NA" as shown below.

1. State your marital status. *

2. Do you have children (biological or adopted) If yes, state number of males and females. *

3. Give the age range of your children (e.g. 5-12). If No children, state NA. *

4. Are you on any prescription or over-the-counter medication, or did you take any vaccines currently (in the last three years)? *

Yes
No

5. If yes to any part of #4, list all the medications and vaccines you are currently using, the dosages or number of shots, the health problem each is for, and how long you have been using it. Start each medication on a new line. If No to any, state NA for prescription or vaccines. *

6. Have you used, or are you using alcohol or any illegal drugs? *

Yes
No

7. If Yes to #6, which one/s? If No, state NA. *

8. Have you been depressed for more than two weeks? *

Yes
No

9. Have you ever tried to commit suicide? *

Yes
No

10. Are you able to focus and complete your work? *

Yes
No

11. Are you able to make decisions and follow-through with them? *

12. Are you settled in a fulfilling career? *

Yes
No

13. Do you see yourself as valuable? *

Yes
No

14. If No to #13, state your concern. If Yes, state "how."

15. Do you have conflict in your family? *

Yes
No

16. If Yes to #15, state the problem. If No, state NA. *

17. Do you have conflict with your peers at school or work? *

Yes
No

18. If Yes to #17, state the problem. If No, state NA. *

19. Describe yourself and your present emotions (feelings). Do you feel sad, depressed, angry, happy, fulfilled, guilty, worried, anxious, or fearful? *

20. How do you rate your intellectual ability to read, understand, and apply information? *

21. Do you find yourself forgetting information and events, and becoming frustrated, agitated, or angry? *

Yes
No

22. Do you have self-control in relation to appetite and sexual relationships? *

23. Were you, or are you a victim of physical, sexual, verbal, emotional, and/or financial abuse? *

Yes
No

24. If Yes to #23, did you receive psychological counseling? *

Yes
No
NA

25. Who did you live with until age 18? *

26. How was the experience in your family of origin? *

We had great relationships
Had lots of conflict
Had conflict and abuse

27. What role has your father played in your life to date? *

28. Briefly, describe two happy occasions in your family of origin. *

29. Briefly, describe two traumatic experiences in your family of origin. *

30. Briefly, describe two happy occasions in your current family. *

31. Briefly, describe two traumatic experiences in your current family. *

32. Who are the person/s that comprise your support system? *

33. What is your height in "inches?" *

34. What is your waist measurement in "inches?" *

35. What is your weight in "pounds?" *

36. What is your average blood pressure reading? State systolic/diastolic, --/--. If you do not know, type "?" *

37. What is your average pulse reading? If you do not know, type "?" *

38. What are your average fasting and postprandial, (2 hours after a meal) blood glucose readings? If you do not know, type "?" *

39. What was your last cholesterol total reading? If you do not know, type "?" *

40. Specifically, what were your last LDL, HDL, and triglyceride cholesterol readings? State each clearly on a different line. If you do not know, type "?" next to each. *

41. What is your regular bedtime (approximately)? *

42. On average, how many hours of sleep do you get nightly? *

43. What is/are your sleep practices? *

44. On average, how much distilled or filtered, room temperature water (8oz. cups) with a total of 1/2 tsp. pink salt do you drink daily? *

45. Do you stick to eating at specific times daily? *

Yes
No
Sometimes

47. Which of the following is your practice? *

Carnivore, eat all meat
Carnivore, eat only clean meat
Vegetarian, eat dairy, but no meat
Vegan, eat no meat and dairy

46. How many meals do you eat daily? *

1
2
3
4-7

48. What kind of foods do you eat? *

All natural raw and cooked
Natural and processed
Sugar and processed
Processed foods and snacks

49. List the time and items you generally have for breakfast. Indicate whether or not you have liquids with your meal and if you have both fruits and vegetables together? Do you walk 15-30 minutes after the meal? *

50. List the time and items you generally have for lunch. Indicate whether or not you have liquids with your meal and if you have both fruits and vegetables together? Do you walk 15-30 minutes after the meal? *

51. List the time and items you generally have for supper. Indicate whether or not you have liquids with your meal and if you have both fruits and vegetables together? Do you walk 15-30 minutes after the meal? *

52. What do you snack on and at what times of the day do you snack? Start each on a new line. *

53. Do you chew your food until it becomes liquid before swallowing it? *

Yes
No

54. Do you drink green tea, coffee, chocolate tea, sodas, and alcoholic beverages? If so, state which ones and how much (in ounces or liters) you drink daily. *

55. Do you drink juice? If so, what kind and how much (in ounces or liters) do you drink daily? *

56. Do you cook oats, grains, and beans for at least 3-hours in low heat? *

Yes
No

57. Are you taking supplements? If so, state each supplement, dosage amount, the brand's name, and the length of time you have been using them. Start each supplement information on a new line. *

58. How many days per week do you exercise for at least 30 minutes? *

0
1-3
4-5
6-7

59. Does your exercise include the following *

60. Do you get 2-3 full-body Lymphatic Drainage Massages each week? *

Yes
No

61. Do you practice deep breathing 3-5 times daily? *

Yes
No

62. Do you practice daily detoxification using food, herbs, an infra red sauna, or body scrub? *

Yes
No

63. Do you intentionally get 15-45 minutes sunlight 4-7 days per week or use vitamins D3, 4,000-5,000 iu daily; a large green vegetable salad and 8-16 oz. green juice/smoothies, or an alternative vitamin K2 daily? *

Yes, always
Yes, 1-3 times per week with green vegetables as a side-dish
Yes, 1-3 times per week with no green vegetables
No, some sunlight, and some green vegetables or K2
No, some sunlight, no green vegetables, and no K2
No sunlight and some green vegetables
No sunlight and little or no green vegetables

64. What is your choice of music? *

65. Which recreational activities are you involved in? *

66. On an average, how many hours per day do you spend on recreational activities? *

67. Do you have a day of rest in God to reflect, find strength to go on, and to create strong bonds with family and friends? *

Yes
No

68. Do you trust God with all your life's situations, joys, and sorrows? *

Yes
No

69. What message/s about your abilities and self-worth do you tell yourself daily? *

70. Briefly, give your family history. Include health (lifestyle diseases, mental health disorders, addictions), emotional-relational (dysfunctions and abuse), and spiritual issues (family worship, church attendance). *

71. Is there a person/s you have not forgiven for a wrong done to you or someone you love? *

Yes
No

72. What regrets do you have and why? *

73. If you are given the opportunity to start-over life, what would you do differently? *

74. What is your purpose and dream for the rest of your life? *

75. Do you spend time in thanksgiving to God daily? *

Yes
No

MY COMMITMENT TO CHANGE. I am willing and determined to work with the psychologist-health coach to make necessary changes for health and success. *

Yes
No

Your message or comment on your emotional and physical health, or any area of concern affecting you. Include recent tests and results as well as any reoccurence of problems.

Your digital signature *

State the date (mm/dd/yr) of your commitment. *