Department of Physiology

AIIMS NAGPUR

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I-Lifestyle Medicine Assessment (Short Screening Questionnaire)

Personal Information :

Full Name*

Registration ID* :

For each item, think about the last seven days and answer ‘Yes’ or ‘No’ if you…
1.
Felt your life had a sense of purpose
Yes
No
2.
Used olive oil as your primary oil or used no oil when cooking
Yes
No
3.
Engaged in two or more spiritual or religious practices (e.g., meditation, prayer, church services, etc.)
Yes
No
4.
Felt that you were able to manage and deal with stressors effectively most days
Yes
No
5.
Interacted with one or more club(s) or organization(s) (e.g., athletic, community, school group, etc.)
Yes
No
6.
Smoked, vaped, or used tobacco/e-cigarette
Yes
No
7.
Visited or spoke to a close friend or family member on three or more separate occasions
Yes
No
8.
Woke up feeling refreshed and rested on most days
Yes
No
9.
Spent at least two hours in nature (approximately 20 minutes daily)
Yes
No
10.
Felt you had enough time to take care of yourself most days
Yes
No
For each item, think about the last seven days and provide your best estimate for each:
less than 1 1 2 3 4 5 6 7 8 9 10+
11 Total number of sit-down or take-out restaurant meals
12 Total number of resistance training workouts performed (e.g., pushups, squats, pullups, etc.)
13 Total number of sweetened drinks consumed (e.g., juice, sweetened coffee or tea, soda, sports drinks, etc.)
14 Highest number of alcoholic drinks consumed on any single day
15 Average number of packaged snacks per day (e.g., chips, crackers, cookies, candy, protein bars, etc.)
16 Average number of hours slept per night
17 Average number of daily servings of fruit
18 Average number of hours spent sitting each day
19 Average number of alcoholic drinks consumed on days alcohol was consumed (select less than one if you did not drink any alcohol)
20 Average number of daily servings of vegetables
21 Total amount of cardiorespiratory exercise during the week (e.g., brisk walk, jog, etc.)
less than 30 minutes 30 minutes 45 minutes 1 hour 1.5 hour 2 hours 2.5 hours 3 hours 3.5 hours 4 hours 4.5 hours 5 or more hours


Connection points: sum item numbers: 1, 3, 5, 7, 9
Movement points: sum item numbers: 12, 18, 21
Substance use points: sum item numbers 6, 14, 19
Recovery points: sum item numbers: 4, 8, 10, 16
Nutrition points: sum item numbers: 2, 11, 13, 15, 17, 20
Lifestyle score equals the sum of all five domains (50 points total):
Overall Lifestyle Score Interpretation
Interpretation Overall Lifestyle Score
This is an opportune time to work with your provider to help you adopt habits that will significantly improve your health. Below Average 0-20
You have some great health habits, though there is ample opportunity to improve your health and decrease your disease risk. Average 21-30
You have many healthy habits, though there are a few areas that you should assess your habits in to see if you can improve them. Very Good 31-40
You’re doing great, though there are a few minor tweaks to your lifestyle you can make that will lead to better overall health. Excellent 41-50

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