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Worksheet

Level 1 Starting Evaluation

Please read each question carefully and answer honestly with where you're currently at.

1. ➜

Primary Symptom/ Diagnoses (select one or more)

2. ➜

If answered "Other" to the previous question: Please list here

3. ➜

Physical Function: What is your overall functional capacity on a scale of 1-10?

1 being the lowest score "I am bedbound and/or housebound"

10 being the highest score "I am physically able to engage in all of the daily activities I desire"

4. ➜

Emotional/Mental Function: How much of your day are you experiencing a stress response on a scale of 1-10?

1 being the lowest stress score "I rarely feel stressed"

10 being the highest stress score "I always feel stressed"

5. ➜

If you have had fatigue: How would you rate the fatigue you experience currently?

1 being the best "I only experience fatigue occasionally and can function well overall"

10 being the worst "Fatigue is terrible - I barely have energy at all"

6. ➜

If you have had pain: What would you rate the pain you experience currently?

1 being the least "I experience little to no pain"

10 being the worst  "The pain I experience is incapacitating"

7. ➜

Which of these statements do you feel most resonates with your current quality of life? Where do you feel you fit between these two statements on a scale of 1-10?

1 being the least "I find it challenging to maintain a sense of well-being and purpose in life"

10 being the best "I feel a strong sense of well-being and purpose in life"

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