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The TROUBLE Assessment

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On the Comprehensive Assessment there are a number of questions that ask for 1 – 10 rating. For these questions use this scale: 1 = Never, 3 = Sometimes, 5 = 50/50, 7 = Mostly, 10 = Always. Don’t think too much about your answer. Research has shown that if you go with your first impression your answer is more accurate than if you spend time trying to figure it out. 

[  ] My shots are up to date (see below for names and indications)
[  ] My tests are up to date (see below for names and indications)
[  ] The last time I had a full physical exam was: Month _____ Year ________
[  ] I do not take medicine
[  ] I take medicine as prescribed by my doctor
The last time I had a full physical exam was:Month _____ Year ________




Flu Month _____________ Year _____________
Tetanus  Month _____________ Year _____________
Pneumonia Month _____________ Year _____________
Shingles Month _____________ Year _____________
Varicella Month _____________ Year _____________
HPV Month _____________ Year _____________




Sodium, Potassium, BUN and Creatinine Month _____________ Year _____________
Kidney function  Month _____________ Year _____________
Liver function Month _____________ Year _____________
U/A Month _____________ Year _____________
TSH Month _____________ Year _____________
Vitamin D level Month _____________ Year _____________
Bone Density Month _____________ Year _____________


Physical Exam


The last time I saw my doctor  Month _____________ Year _____________
The last full physical exam with my doctor Month _____________ Year _____________

[  ] I would like these results sent to my doctor 

What does your inheritance include


Have your blood relatives, whether they are still alive or not, ever been diagnosed with the following: 

[  ]  I don’t know my family history

[  ]  Yes[  ]  No[  ]  I don’t know Heart disease Father or brother age 55, or mother or sister before age 65
[  ]  Yes[  ]  No[  ]  I don’t know Diabetes Mother, father, sister, brother, son or daughter at any age
[  ]  Yes[  ]  No[  ]  I don’t know Stroke Mother, father, sister, brother, son or daughter at any age
[  ]  Yes[  ]  No[  ]  I don’t know Colon or rectal cancer Mother, father, sister, brother, son or daughter at any age
[  ]  Yes[  ]  No[  ]  I don’t know Prostate cancer Father or brother at any age
[  ]  Yes[  ]  No[  ]  I don’t know Breast cancerMother or sister at any age
[  ]  Yes[  ]  No[  ]  I don’t know Lung cancerFather or Mother at any age



Life is meant to be fun and active! Our bodies thrive with “playing.” Going from sitting at work and home to putting 20 or 30 minutes of walking or playing (moving around) can cut your risk of heart attacks or strokes in half. It also helps you lose weight, relieve stress, reduce blood pressure and the risk for diabetes and osteoporosis. 

On average, how many times per week do you engage in physical activity of at least 20 minutes?
[  ] 1 or less[  ] 2-4[  ] 5 or more
What is your current exercise level? 
[  ] Low[  ] Moderate[  ] High


Minutes of exercise per week : min
Average number of steps per day (using a pedometer) : steps


1-10 I am active and play for at least 150 minutes per week or over 10,000 steps/day.
1-10 I incorporate resistance training (core training, callisthenic or weights) in my program.
1-10 I incorporate aerobic activity (running, swimming, biking, skating, dancing, circuit training, active work or play) into my exercise program.
1-10 I incorporate flexibility exercises (pilates, yoga, stretching) into my exercise program.



Are you overweight or obese? These conditions will shorten, or decrease how long and how well you live. Obesity is linked to just about every health problem, including cancer, heart disease, strokes and diabetes. The best way to avoid or treat obesity is to maintain good eating habits, watch out how much you eat, and “play” as much as possible. 

QUICK ASSESSMENT – calculating your Body Mass Index   (BMI):
Height: In Inches In Centimeters
Weight: In Pounds In Kilograms


Waist In Inches In Centimeters
Neck Circumference  In Inches In Centimeters
Body Fat %


1-10  I monitor and manage the quantity of food I eat (like the Hand Signals of Health), especially when eating out!
1-10 I eat balanced meals and snacks (lean protein, healthy carbohydrates and fats).


OIL = Lipids 

How much fat do you have floating in your blood? Is it healthy fat (HDL) or lethal fat (LDL)? Is there extra energy (triglycerides) present in your blood? Energy you take in (food) when it comes from saturate or trans fat increase the lethal fats; monounsaturated fats and burning energy (exercise) use the triglycerides and elevate the HDL. 

[  ] I do not know what my cholesterol, triglycerides or HDL are
[  ] My cholesterol, triglycerides and HDL are within normal limits
[  ] I am being treated for an abnormal LDL, HDL, or triglycerides
[  ] I take fish oil (omega 3) supplements every day


Cholesterol mg/dl Month Year
Triglycerides mg/dl Month Year
LDL-C  mg/dl Month Year
HDL-C mg/dl Month Year
VAP Month
Liposcience Month
Berkley Month


- Servings of red meat per week 


1-10 I am a success in reducing saturated fat (e.g. whole milk, fried foods, processed foods and fatty meats), trans fats (processed foods), refined carbohydrates (made from white flour and sugar), and high fructose corn syrup (prepackaged food) – read the labels!!
1-10 I successfully add monounsaturated fats (nuts, avocado, + olive products) and deep water fish (or fish oil supplements) to my diet.



Sugar (glucose) in your blood is vital for good health. Taking in foods with high levels of sugar causes extra stress inside the body. Weight gain, high blood pressure, diabetes, heart attacks or strokes, and other diseases soon begin to appear in your body. Over 5 – 15 years this will lead to diabetes. Discovering this problem inside your body and taking action can prevent this from occurring! The longer you wait the harder it is to stop or reverse! 

 [  ] My blood sugar is always normal.
 [  ] My blood sugar before a meal is sometimes between 100-125 or hours after a meal between 140 and 180.
 [  ] I have diabetes.
 [  ] I do not know my blood sugar.


I eat a rainbow of vegetables and fruits at the first part of my meals each day. 1-10


Glucose                 mg/dl Albumin       mg/dl C peptide      mg/dl
PreDx Score 1 – 10 Insulin mg/dl Hb A1C mg/dl



When your heart pumps it leads to more pressure in the arteries, when it relaxes the pressure is lowest. How hard your heart has to work to move the blood and how strong your heart is determines how long and how well your heart lasts. Eating salt (sodium), gaining weight, and not exercising are three ways to make this worse. Over time this leads to heart and kidney failure, strokes, eye damage and heart attacks. Keeping the blood pressure under control makes a big difference in your health! The way you eat and exercise, the weight you maintain, and the supplements and medicine you take can make a big difference to you. 

 [  ] My blood pressure is always normal
 [  ] My blood pressure is sometimes greater than 140/90
 [  ] I take medicine for high blood pressure
 [  ] I do not know my blood pressure


I add salt (sodium) to my food y/n
I read labels and try to keep the sodium (Na) under 2000 mg/day y/n


Blood pressure mm Hg Mm Hg Heart rate bpm



Lousy habits drive and worsen, or improve and lessen, many health problems. Our hearts and brains are especially susceptible to cigarette smoking or chewing tobacco, excess alcoholic consumption, poor eating habits, not drinking enough water and poor sleep habits. Correcting these will increase the quality and length of your life!

 [  ] I have more than 2 glasses of wine, beers, or ounces of hardalcohol per day 
 [  ] I currently smoke cigarettes or chew tobacco
 [  ] I get less than 54 hours of sleep per week


Do you currently consume alcohol? 12 oz beer
[  ] Yes 5 oz wine
[  ] No 1 oz liquor
Do you currently use tobacco? Packs/day
[  ] Yes Chews/day
[  ] No


I sleep at least 54 hours each week.
I am consistent with the time of night that I go to sleep and/or the time of morning that I wakeup.
I reach my water-drinking goal every day (enough water to make my “water” clear or light yellow).
I substitute water for sugared and/or caffeinated beverages.



Heart attacks and strokes occur when a plaque containing cholesterol breaks open. Age, high lipids, high sugars, sleep deprivation, weight gain, high blood pressure and/or tobacco have drive the buildup of plaque – lowering or eliminating these slow the process. Cancer occurs when cells in the body begin to grow out of control. Our immune system tries to monitor and prevent this from happening. Many of the same things that lead to plaque build up lead to increased risk of cancer. 

 QUICK ASSESSMENT: I have been diagnosed with the following
 [  ] Heart disease
 [  ] Cancer
 [  ] Lung disease


 [  ] Heart attack
 [  ] Heart surgery
 [  ] Angioplasty or stent
 [  ] Stroke
 [  ] Emphysema
 [  ] Heart failure
 [  ] Mitral or aortic valve disease or heart murmur
 [  ] Other cardiovascular disease
 [  ] Enlarged heart
 [  ] Atrial fibrillation
 [  ] Lung cancer
 [  ] Colon or rectal cancer
 [  ] Prostate cancer


PSA Month Year
Colonoscopy Month Year
Mammogram Month Year
Pap Smear  Month Year
Hs CRP  Month Year
Lp PLA Month Year
CTA Month Year
Calcium score Month Year



Stress makes a big difference in the choices you make. How much we eat, exercise, take care of your self and how well your immune system and other body systems operate are directly affected. This increases or decreases the quality of your life. Recognizing and treating stress can be very challenging – often it changes slowly so you fail to notice it getting worse. Addressing and managing it improves relationships and the fun you have. 

1-10 I am aware of my body and take deep breathes to manage my stress.
1-10 I put aside time to practice deep breathing exercises (the relaxation response, progressive relaxation, or meditation).


1-10 I spend time with friends who call me to be my best and encourage me in my life.
1-10 I give without expectation to the people with whom I come in contact.
1-10 I forgive myself and others for things that don’t go well.


1-10 I am living a life of freedom and peace.
1-10 I am grateful for all that I have been given in life.
1-10 I am managing the things I control, encouraging those I influence, and trusting things will work out with the things I don’t control.


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