Elena Klimenko, MD, IFMCP
280 Madison Avenue #905
New York, NY 10016
(212) 696-4328
First Name*
Last Name*
To help evaluate your state of wellness, please fill out the following questionnaire. Select yes or no for each question, and note in the Comments sections any additional concerns related to each category. After reviewing your answers, your health care provider will discuss options to improve your wellbeing.
Do you eat organically
grown and in season
Do you eat cold water
fish such as wild caught
salmon or cod at least
twice a week?
Do you eat five different
colors of vegetables per
Do you eat enough
vegetables to meet your
fiber needs?
Do you fast at least 12
hours three or more times
per week?
Do you chew your food
thoroughly, until it is a
paste, before swallowing?
Do you suffer from
regular bouts of
diarrhea, bloating or
Do you regularly drink
soda (diet or regular)?
Do you take antacids or
proton pump inhibitors
such as Prilosec,
Prevacid, Protonix or
Do you eat out more than
twice a week?
Do you regularly get
muscle cramps?
On a scale of 1-3, with 1
being poor and 3 being
great, how is your diet?
Nutritional Wellbeing -
Do you watch TV or work
on your computer/tablet
less than two hours per
Do you get outside most
days of the week for at
least 10 minutes?
Do you participate in
physically active hobbies
such as gardening or
Do you participate in a
formal exercise program?
Do you perform easy
Do you perform exercises
that elevate your heart
Do you regularly have
muscle or joint pain?
Do you take prescribed or
medications on a regular
basis for joint pain or
muscle pain?
Have you had surgery for
any musculoskeletal
conditions such as knee,
shoulder or back pain?
Have you been diagnosed
with arthritis, chronic
fatigue syndrome or
Do you exercise less than
three times or more than
five times per week?
On a scale of 1-3, with 1
being poor and 3 being
great, how is your
physical health?
Physical Wellbeing -
Do you participate in
group activities at least
three times per week?
Do you sleep seven to
eight hours a night
without the help of
Are you spiritually
active at least four
times per month (e.g.
meditate, participate in
church activities,
Do you eat some of your
meals with family or
friends every day?
Do you have one or more
Do you practice stress
management technique such
as deep breathing?
Do you frequently
experience anxiety,
mental fogginess, trouble
concentrating, or
Do you wake up more than
twice a night, need an
alarm clock to wake up,
or feel tired/sluggish
once you wake up?
Do you consider your job,
personal relationships or
finances stressors in
your daily life?
Do you care for a parent
or a disabled family
Do you feel lonely?
On a scale of 1-3, with 1
being very stressed and 3
being not stressed at
all, how stressed are
Emotional Wellbeing -
Do you avoid drinking
from plastic bottles/cups
and eating food from
plastic plates or
Do you eat organic?
Do you grow your own
fruits or vegetables?
Are you free of physical
threats (e.g. personal
relationship, workplace)?
Are you free of emotional
toxins (e.g. personal
relationship, workplace,
Do you use organic
cleaners such as soap,
detergent, and shampoo?
Do you smoke or vape, or
are you regularly exposed
to secondhand smoke?
Have you lived or worked
in a place with known
Do you get sick often or
have you taken
antibiotics in the last
two years?
Do you have mercury
fillings or had all your
mercury fillings removed
at the same time?
Have you been exposed to
lead or other heavy
metals (e.g. tin,
aluminum, mercury)?
On a scale of 1-3, with 1
being poor and 3 being
very good, how would you
rate the quality of your
Environmental Wellbeing -

Disclaimer: This tool does not provide medical advice. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read here or anywhere online. If you think you may have a medical emergency, immediately call your doctor or dial 911.

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280 Madison Avenue #905 New York, NY 10016
(212) 696-4328
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