HEALTH QUESTIONNAIRE
How healthy do you think you are on a scale 1-10 (1 being extremely unhealthy and 10 being extremely healthy)?_________
How energized do you feel on daily bases, use the scale 1-10 again? Do you wake up in the morning full of energy, looking forward to start your day or?____
Mark your answer to following questions, choose A,B or C:
Following means:
Sometimes= twice a week or less
Often = More than twice a week
Rarely= Less than once a week
1. Do you eat 4-6 meals a day ? A.Most of the time B.sometimes C.Rarely
2. Do you eat at least 2-3cups
or more vegetables a day? A.Most of the time B.Sometimes C.Rarely
3. Do you eat at least a cup of
raw vegetables a day? A.Most of the time B.Sometimes C.Rarely
4. Do you eat 1-3 fruits a day? A.Most of the time B.Sometimes C.Rarely
5. Do you eat fast food or readymade meals? A. Rarely B.Sometimes C.Frequently
6. Do you eat fish A.Frequently B.Sometimes C.Rarely
7. Do you eat sweets, cakes, snack bars biscuits,
chips and Other processed foods? A.Rarely B.sometimes C.Frequently
8. Do you eat meat, chicken or meat products
non-organic? A.Rarely B.sometimes C.Frequently
9. Do you drink milk or eat milk products
like cheese, yogurt etc? A.Rarely B.sometimes C.Frequently
10. Do you include healthy fats like olive oil, coconut,
seeds and nuts in your diet every day? A.Most of the time B.Sometimes C.Rarely
11. Do you eat fried food? A.Rarely B.sometimes C.Frequently
12. Do you eat refined carbs:
bread, rice, pasta, noodles etc? A.Rarely B.sometimes C.Frequently
13. Do you drink 2-3 liters of water a day? A.Most of the time B.Sometimes C.Rarely
14. Do you drink alcohol? A.Rarely B.sometimes C.Frequently
15. Do You smoke? A.Rarely B.sometimes C.Frequently
16. Do You take medicines? A.Rarely B.sometimes C.Frequently
17. Do you drink coffee and black tea? A.Rarely B.sometimes C.Frequently
18. Do you spend at least an hour outdoors? A.Most of the time B.Sometimes C.Rarely
19. Do you spend more than 4 hours a day in front of
the computer, on the phone or
around other electronics? A.Rarely B.ometimes C.Frequently
20. Do you exercise 3 times a week or more A.Most of the time B.Sometimes C.Rarely
21. Do you experience stress or
any other negative emotions? A.Rarely B.sometimes C.Frequently
• For each “A” you checked, give yourself no credit (0)
• For each “B” you checked, give yourself credit of one point (1),
• For each “c” you checked, give yourself credit of two points (2)
Add up all 21 answers. You will fit within one of the following categories:
SCORE 0-10
A score in this range means that, generally, you are healthy. You may have some habits that are change-worthy. You can identify these by reviewing the answers that you circled “B” or “C” ’.
SCORE 11-21
This range suggests that you are demonstrating a pattern that, in a number of instances, runs counter to good health. You can still learn some remarkable things that will help you to get better results.
SCORE 22-31
score in this range indicates that you have a lifestyle that threatens your health and wellbeing. You need to pay closer attention to what you eat and how you live your life in order to make the substantial changes needed. Accept this challenge and do not give up on yourself.
SCORE 32-42
If your score falls in this range, you will have to start making significant changes in your lifestyle, if you want to experience being healthy. Make a concerted effort to initiate change immediately.
Helga Bergsteinsdottir Health and Wellness coach
BA in Nutrition and fitness, NLP master practitioner, BA psychology
Tel Island 8458174