Assessment Form Complete the form below and then submit it. “Doesn’t matter if you can dream it or not, all that matters is if you can begin it or not? Take that first step.”― Vikrmn Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Why have you decided to undertake this assessment?What are you expecting to achieve if you complete the MMM Program?Briefly describe your goals and expectationsSelect what describes your daily mood bestStable but less than satisfactoryUp and down but less than satisfactoryMostly lowAlways low and negativeNo issuesList any current diagnosis you have and who gave itInclude any Diagnosis you Believe you may haveList any past diagnosis you have and who gave it Include any diagnosis you believe you may have hadList current prescribed medicationsInclude medications you are not be takingList Past prescribed medicationsIt is ok if you are unable to be Specific, do your bestWhat makes you unhappy?Describe personal factors and external. Please be brief. Do you struggle to maintain a regular schedule? Do you have issues with the people around you? Do you have issues with your family? Do you see anybody for therapy?A brief description of why and what you are achievingDescribe your level of fitnessDo you participate in Sports and Classes. How regularly do you exercise. How do you feel about your level of fitness?If you are comfortable, describe briefly any perceived trauma which may be affecting you nowPlease be brief. This assessment is not intended to be a counselling session. The focus is intervention based. Select what describes your general mood best Stable but less than satisfactoryUp and down but less than satisfactoryMostly lowAlways low and negativeNo issuesSelect which comment describes you daily stress levels the bestAlways stressed and can never switch offMostly stressed but can switch off sometimesI manage my stress wellI don't feel stressed but others think I amMy mood is too low to feel stressedWhat describes your character the bestI am usually a happy personI an usually a negative personI am usually not assertiveI am assertive or aggressiveI have mood swingsI use alcohol NeverSociallyTo sleepTo relaxDaily but moderately (less than than 4 heavy beers or half a bottle of wine)HeavilyI use cannabisNeverMonthlyWeeklyDailyHeavilyJust CBDI use Illegal drugsPossibly but do not wish to discussI don't want to give this informationYes but it's not a problemYes, it's a problemDailyHeavilyI have addiction problemsWhich of the following applies to youI would you like to cease medicationMedication is no longer workingI am overweightI have stomach and bowel issuesI have sleep issuesI feel stuck in my lifeI am not open to new ideasI feel there must be other answers about my health but I am confusedMy life is chaotic and disorganizedI am religiousI am agnosticI have conflict with most of my familyI have significant relationship issuesIs there anything else of relevance?Please include details of psychiatric admissions, suicidality self harm etc if relevantI am legally recognized as an adult and I agree that this Assessment does NOT constitute Medical Advice but is for Educational purposes onlyYesNoI will undertake due diligence and will make any changes to my Health in Consultation with an Appropriately Trained Health ProfessionalYesNoThe Information I have Provided is Accurate. The MMMHappiness Group will be in no way Lible for any Decisions I may make with my Health after Receiving Feedback from this AssessmentYesNoGeneric Information ( Assessment Part 2: Consumption Patterns )Weekly work hours, relationship status, children, stress management strategies, hobbies and how regular, what takes up your time, what type of exercise do you do, how much, how often What describes your usual day best?I do nothing all dayI never have enough timeI have lots to do but never have the energy to do itWhich statements describe your lifestyle best?I get up early nearly every day and I am always running aroundI have lots to do but never have the energy to do itI watch TV and/or YouTube to relaxMy job/study is stressfulI work/study too many hoursI never have enough timeI get distracted easily by Social Media or TVI watch TV and/or YouTube to relax before bedMy job/study is psychically exhaustingI spend most of my time indoorsPlease select more than oneScreen TimeMy work day,. on average, involves more than 4 hours of computer workI watch more than 5 hours of entertainment per dayMy total screen time per day is less than 3 hoursMy total screen time per day is 6 to 10 hoursMy recreational screen time is mostly reality entertainmentMy recreational screen time is mostly light fiction entertainmentMy recreational screen time is mostly voyeuristic entertainmentI watch more than 3 hours of entertainment per dayI watch more than 8 hours of entertainment per dayMy total screen time per day is 3 to 6 hoursMy total screen time per day is more than 10 hoursMy recreational screen time is mostly dark fiction entertainmentMy recreational screen time is mostly news and current affairs entertainmentOn my days off, I use forms of electronic media to unwindScreen time includes all forms of engagement, from mobile phone games, social media, TV, Netflix on PC, Work situation involving computers etc. I love exerciseYesNoI enjoy meditationYesNoI eat takeoutYesNoRarelyDo you have a particular diet?VeganVegetarianIntoleranceDiabeticLow fatOrganicPaleoWhat describes your diet best?I have a sweet toothI like comfort foodI have potatoes, chips, fries or bread with most mealsI am careful about what I eatI am totally confused about nutrition but try my bestI eat everythingWhich statements describe your fluid intake the bestMostly waterI dislike drinking waterSweet drinksCaffeinated drinksHalf and half water and other dependingMainly sodaI like energy drinks and consume them dailyI cant function without energy drinks or caffeineWhich statements describe your food intake the bestI cook with packaged and frozen foodsI mostly try to cook with fresh ingredientsI eat a lot of re-heatable frozen mealsI dislike variety and eat the same things regularlyI dislike fermented foodsI add extra salt or sauces to everythingThere is little difference between Grain fed and Grass fed meatYesNoThere would be a benefit to me eating organic foodStrongly DisagreeDisagreeUnsureAgreeStrongly AgreeCommentSubmit
