Constitutional Health Assessment Questionnaire Form
Please complete this questionnaire to help assess your general constitutional health. Answer each question as accurately as possible.
In the past week, how would you rate your overall energy levels?
*
1
2
3
4
5
How often do you feel rested after a night's sleep?
*
Always
Often
Sometimes
Rarely
Never
Please indicate how frequently you experience the following symptoms:
*
Rows
Never
Rarely
Sometimes
Often
Always
Headaches
1
2
3
4
5
Digestive discomfort
6
7
8
9
10
Muscle aches
11
12
13
14
15
Mood swings
16
17
18
19
20
How would you rate your usual appetite?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How many days per week do you engage in physical activity (at least 30 minutes)?
*
Please Select
0 days
1-2 days
3-4 days
5-6 days
7 days
How would you describe your usual mood?
*
Calm
Anxious
Irritable
Depressed
Other
How would you rate your ability to handle stress?
*
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
How satisfied are you with your current physical health?
*
1
2
3
4
5
How often do you feel mentally alert during the day?
*
Always
Often
Sometimes
Rarely
Never
Please share any additional comments or concerns about your general health.
Submit Assessment
Should be Empty: