inflammation_survey.docx
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Are you inflamed? *

I have chronic aches and pains such as back pain, neck pain, headaches, or generalized muscle or joint pain.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I am overweight.     www.nhlbisupport.com/bmi/

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

It is hard for me to lose weight/fat.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I can grab too much fat around my waist.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I do not exercise regularly.

 Strongly Agree (0 day/week)

 Agree (1-2 day/week)

 Neutral (3 day/week)

 Disagree (4 day/week)

 Strongly Disagree (>5 day/week)

Reset



I don’t feel well when I exercise.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I have difficulty recovering from moderate to light exercise.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I am physically lethargic.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I am mentally lethargic and feel rundown and depressed more than I would like.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I get at 7-8 hours of restful sleep every night.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I am anxious most of the time.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I worry about most things.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I feel down most of the time.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I suffer from one or more of the following: Frequent cold symptoms, frequent flu symptoms,
frequent allergies, arthritis, fibromyalgia, chronic fatigue syndrome, sinusitis, acne, asthma,
digestive conditions, dysmenorrheal, endometriosis, Alzheimer’s disease, Parkinson’s disease,
multiple sclerosis, cancer, heart disease, osteoporosis, hypertension, depression, the insulin
resistance syndrome (Pre-diabetes), or diabetes.


 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I regularly take anti-inflammatory or anti-pain medications, such as: ibuprofen, aspirin, or
Tylenol®, or  prescription pain medications.


 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I regularly eat refined sugar. Including table sugar, desserts, soda, sweetened drinks, etc.  Be honest!

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I regularly eat grain products, such as: White bread, whole wheat bread, pasta, cereal, pretzels,
crackers, and any other product made with grains or flours from gains, which includes most
desserts and packaged snacks.


 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I regularly eat partially hydrogenated oils (trans fats) found in most margarines, fast foods, deep fried foods
(French fries, etc.) and most packaged foods.


 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I regularly eat corn oil, safflower oil, sunflower oil, cottonseed oil, soybean oil, peanut oil, and
foods with oils such as mayonnaise, tartar sauce, margarine, and nearly all salad dressings.


 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I regularly eat meat and eggs from grain-fed animals. (Regular supermarket brands).

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I regularly drink or eat dairy products in greater than condiment size.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset

I regularly consume soy or soy products, or eat them in place of fruits and vegetables.

 Strongly Agree

 Agree

 Neutral

 Disagree

 Strongly Disagree

Reset