CHEMICAL INTAKE PROFILE
Give yourself a score out of ten,
appropriate for your performance on each of the ten questions below.
A good score is a high score. A bad score is a low score.
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1. |
Do you smoke? If yes, score 0.
If no score 10 |
Yes |
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No |
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2. |
How many standard alcoholic drinks do you have a week?
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>20 |
20 |
15 |
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13 |
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11 |
10 |
9 |
5 |
5 or less |
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0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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3. |
Do you drink too much caffeine - coffee, cola drinks ... How many cups a day? |
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>5 |
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5 |
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4 |
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3 |
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2 |
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1 |
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0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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4. |
Are you a high salt eater? |
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High |
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Low |
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0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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5. |
How do you rate your reliance on anti-inflammatory tablets? |
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High |
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Low |
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0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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6. |
How do you rate your reliance on headache, migraine and pain-killing tablets? |
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High |
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Low |
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8 |
9 |
10 |
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7. |
Do you take sleeping tablets, hypnotics, relaxants ...? |
Yes |
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No |
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8. |
Are you on antidepressants? |
Yes |
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No |
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9. |
Are you on blood pressure tablets? |
Yes |
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No |
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10. |
Are you on diabetes tablets? |
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Yes |
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No |
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Score/100 |
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Attained more than 7/10 on all items Yes
o
No
o
Attained more than 70/100
Yes
o
No
o
YOUR
HEALTH AND FITNESS IS ASSESSED AS: -
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Excellent if you scored over 90 |
o |
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Very good if you scored over
80 |
o |
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Very good if you scored over
80 |
o |
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Good if you scored over 70 |
o |
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Not bad 60 - 70 |
o |
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Not good 50 - 60 |
o |
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Poor 40 - 50
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o |
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Not good
less than 40 |
o |
Integrated Health Systems
7 Salvado Place, Stirling (Canberra) ACT 2611 Australia
61 2 6288 7703
