Elena Klimenko, MD, IFMCP
280 Madison Avenue #905
New York, NY 10016
(212) 696-4328
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 foods?
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 day?
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 constipation?
Do you regularly drink soda (diet or regular)?
Do you take antacids or proton pump inhibitors such as Prilosec, Prevacid, Protonix or omeprazole?
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 - Comments
Do you watch TV or work on your computer/tablet less than two hours per day?
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 dancing?
Do you participate in a formal exercise program?
Do you perform easy stretching/balancing exercises?
Do you perform exercises that elevate your heart rate?
Do you regularly have muscle or joint pain?
Do you take prescribed or over-the-counter 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 fibromyalgia?
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 - Comments
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 medication?
Are you spiritually active at least four times per month (e.g. meditate, participate in church activities, prayer)?
Do you eat some of your meals with family or friends every day?
Do you have one or more pets?
Do you practice stress management technique such as deep breathing?
Do you frequently experience anxiety, mental fogginess, trouble concentrating, or depression?
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 member?
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 you?
Emotional Wellbeing - Comments
Do you avoid drinking from plastic bottles/cups and eating food from plastic plates or containers?
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, family)?
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 mold?
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 environment?
Environmental Wellbeing - Comments

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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