HB LIVE Program: Pre-Program Questionnaire for participants of the Hormone Balance LIVE Program. Section 1:Name* First Last Email* Weight*Height*Waist measurement in inches*Hip measurement in inches*Fasting Glucose Level*Fasting Total Cholesterol Level*Fasting LDL Cholesterol Level*Fasting HDL Cholesterol Level*Fasting Triglycerides Level*Blood Pressure*Vitamine D Level*Ferritin Level*Section 2:The following questions ask how you feel about your quality of life, health, or other areas of your life. Please choose the answer that appears most appropriate. If you are unsure about which response to give to a question, the first response you think of is often the best one. Please keep in mind your standards, hopes, pleasures and concerns. We ask that you think about your life in the last four weeks.How would your quality of life?*1 - Very poor2 - Poor3 - Neither poor nor good4 - Good5 - Very goodHow satisfied are you with your health?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedSection 3:The following questions ask about how much you have experienced certain things in the last four weeks.To what extent do you feel that physical pain prevents you from doing what you need to do?*5 - Not at all4 - A little3 - A moderate amount2 - Very much1 - An extreme amountHow much do you need any medical treatment to function in your daily life?*5 - Not at all4 - A little3 - A moderate amount2 - Very much1 - An extreme amountHow much do you enjoy life?*1 - Not at all2 - A little3 - A moderate amount4 - Very much5 - An extreme amountTo what extent do you feel your life to be meaningful?*1 - Not at all2 - A little3 - A moderate amount4 - Very much5 - An extreme amountHow well are you able to concentrate?*1 - Not at all2 - A little3 - A moderate amount4 - Very much5 - ExtremelyHow safe do you feel in your daily life?*1 - Not at all2 - A little3 - A moderate amount4 - Very much5 - ExtremelyHow healthy is your physical environment?*1 - Not at all2 - A little3 - A moderate amount4 - Very much5 - ExtremelySection 4:The following questions ask about how completely you experience or were able to do certain things in the last four weeks.Do you have enough energy for everyday life?*1 - Not at all2 - A little3 - Moderately4 - Mostly5 - CompletelyAre you able to accept your bodily appearance?*1 - Not at all2 - A little3 - Moderately4 - Mostly5 - CompletelyHave you enough money to meet your needs?*1 - Not at all2 - A little3 - Moderately4 - Mostly5 - CompletelyHow available to you is the information that you need in your day-to-day life?*1 - Not at all2 - A little3 - Moderately4 - Mostly5 - CompletelyTo what extent do you have the opportunity for leisure activities?*1 - Not at all2 - A little3 - Moderately4 - Mostly5 - CompletelyHow well are you able to get around?*1 - Very poor2 - Poor3 - Neither poor nor good4 - Good5 - Very goodHow satisfied are you with your sleep?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with your ability to perform your daily living activities?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with your capacity for work?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with yourself?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with your personal relationships?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with your sex life?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with the support you get from your friends?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with the support you get from your friends?How satisfied are you with the conditions of your living place?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with your access to health services?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedHow satisfied are you with your transport?*1 - Very dissatisfied2 - Dissatisfied3 - Neither satisfied nor dissatisfied4 - Satisfied5 - Very satisfiedSection 5:The following question refers to how often you have felt or experienced certain things in the last four weeks.How often do you have negative feelings such as blue mood, despair, anxiety, depression?*5 - Never4 - Seldom3 - Quite often2 - Very often1 - AlwaysDo you have any comments about the assessment?
