Self Assessment

You're welcome to use this self assessment form. It is sent directly to Dr. Dwyer for confidentiality. If desired, Dr. Dwyer will contact you to discuss your health.

Please select the number that most accurately represents your current status.
Section A
1=very poor \| 2=poor \| 3=fair \| 4=good \| 5=excellent
Rate the following:
Your physical health	1	2	3	4	5
Psychological/emotional health	1	2	3	4	5

Section B
1=normal \| 2=slightly evelated \| 3=too high \| 4=very unhealthy \| 5=overwhelmed
Rate the following:
Your level of stress	1	2	3	4	5

Section C
1=never \| 2=rarely \| 3=occasionally \| 4=frequently \| 5=constantly
Rate the incidence of the following in your life:
Fatique or low energy	1	2	3	4	5
Overly worried about small things	1	2	3	4	5
Feeling anxious	1	2	3	4	5
Feeling depressed	1	2	3	4	5
Poor sleep	1	2	3	4	5
Colds/flu/infections	1	2	3	4	5
Allergies/sinus problems	1	2	3	4	5
Indigestion/stomach upset	1	2	3	4	5
Constipation/diarrhea/hemorrhoids	1	2	3	4	5
Accidents/slips/falls	1	2	3	4	5
Dizziness/poor balance	1	2	3	4	5
Difficulty concentrating	1	2	3	4	5
Feeling negative or critical	1	2	3	4	5
Anger/agitation	1	2	3	4	5
Headaches	1	2	3	4	5
Physical pain/discomfort	1	2	3	4	5
Difficulty breathing	1	2	3	4	5
Problems with urination	1	2	3	4	5
Sexual difficulties	1	2	3	4	5
Menstrual difficulties	1	2	3	4	5

Section D
1=major problem \| 2=unhappy with \| 3=fair \| 4=good \| 5=great
Evaulate your feelings relative to:
Your sense of ease and well being	1	2	3	4	5
The level of enjoyment in your life	1	2	3	4	5
Your level of confidence	1	2	3	4	5
Your efforts to maintain your health	1	2	3	4	5
Your diet	1	2	3	4	5
Your level of fitness	1	2	3	4	5
The amount of alcohol you consume	1	2	3	4	5
Your caffeine consumption	1	2	3	4	5
Your need for/use of medications	1	2	3	4	5
Your ability to think clearly	1	2	3	4	5
Your ability to handle problems	1	2	3	4	5
Your ability to handle responsibilities	1	2	3	4	5
Your readiness to get your day started	1	2	3	4	5
Your sense of connection to others	1	2	3	4	5
Relationship with significant other	1	2	3	4	5

Additional Comments:

Would you like Dr. Dwyer to contact you?	Yes		No
If yes, how would you like to be contacted?	Email		Phone
If yes, please provide the following (* = Required):
First Name *
Last Name
Email (* if Email selected)
Phone (* if Phone selected)

Please type the two words.

Staying Healthy Naturally

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Self Assessment