Excerpt from:

How to

Eat, Move and

Be Healthy!
Your personalized 4-step guide to
looking and feeling great from the inside out

by

Paul Chek
A C.H.E.K Institute Publication
San Diego, CA

Reproduced with permission from the author

ISBN: 978-1583870129
2

(CHI Questionnaires - CHEK Health Index)

IMPORTANT DIRECTIONS (PLEASE READ)

1. Answer each question with the response that best fits you. It is recommened that you either
photocopy the questionnaires or record your answers on a separate piece of paper. You will
hopefully be using them again to test your progress, and it will be easier if you do not have your
previous answers in front of you at that point. It is extrememly important to answer the ques-
tions as accurately and honestly as possible. There are no right or wrong answers. Supply the
response that most accurately describes you, not what you think you should answer.
When answering these questions, forget everything you’ve been told about what you should and
shouldn’t eat. Answer the questions based on your gut instinct to how you would prefer to eat if
you could eat what you innately desire.
2. Total your scores for each questionnaire. There are numbers in parentheses after each answer.
Add up the numbers corresponding to each of your responses to get your total score for the sec-
tion.
3. Graph your scores on page 37.
4. Calculate your total score by adding up the scores for each section.

COMPLETE THE QUESTIONNAIRE ONLINE!

Would you like to take all these questionnaires online and have the
score automatically added up for you?
Simply visit www.eatmoveandbehealthy.com and fill out the form to
request access to the CHI Questionnaires online.

28 How to Eat Move and Be Healthy!

 You Are What You Eat 2

1. Do you shop for food less 8. Do you eat quick-cook grains

frequently than every four days? such as Rice-A-Roni, Quaker Oats
or MINUTE rice more often than
___ Yes (1) slow-cooked organic whole grains?
___ No (0)
___ Yes (5)
2. Do you eat more packaged (frozen ___ No (0)
or canned) fruits and vegetables
than fresh? 9. How often do you consume
pasteurized, homogenized milk or
___ Yes (3) cheeses?
___ No (0)
___ Never or very rarely (0)
3. Do you eat more cooked ___ 1-2 times per week (1)
vegetables than raw? ___ 3 times per week (3)
___ 3+ times per week (5)
___ Yes (3)
___ No (0) 10. How often do you eat non-organic
yogurts?
4. Do you eat vegetables with fewer
than two meals daily? ___ Never or very rarely (0)
___ 1-2 times per week (1)
___ Yes (5) ___ 3 times per week (3)
___ No (0) ___ 3+ times per week (5)

5. Do you buy more non-organic 11. Do you eat typical store-bought

vegetables than organic eggs from cage-raised chickens
vegetables? (as opposed to free-range eggs)?

___ Yes (5) ___ Yes (5)

___ No (0) ___ No (0)

6. How often do you use a microwave 12. Do you eat non-organic red meat
oven? more than once every four days?

___ Never or very rarely (0) ___ Yes (3)

___ 1-2 times per week (2) ___ No (0)
___ 3-4 times per week (5)
___ 4+ times per week (10) 13. Do you commonly eat meats
(beef, chicken, turkey) from
7. Do you eat white bread more often sources other than a free-range
than whole grain breads? and hormone-free source?

___ Yes (5) ___ Yes (3)

___ No (0) ___ No (0)

Questionnaires 29
2 14. Do you eat canned fish more 20. Do you use standard white table
frequently than fresh fish? salt?

___ Yes (3) ___ Yes (5)

___ No (0) ___ No (0)

15. How often do you use commercial 21. Do you eat TV dinners or highly-
salad dressings? processed foods more than three
times a week?
___ Never or very rarely (0)
___ once a week (1) ___ Yes (5)
___ twice per week (2) ___ No (0)
___ 2+ times per week (3)
22. How often do you eat from fast
16. How often do you use products food restaurants like McDonald’s,
containing hydrogenated oils? KFC, Wendy’s, etc…?

___ Never or very rarely (0) ___ Never or very rarely (0)
___ once a week (1) ___ 1-2 times per week (2)
___ twice per week (2) ___ 3 times per week (5)
___ 2+ times per week (5) ___ 3+ times per week (10)

17. Do you eat nuts or seeds that 23. How often do you eat snacks from
are roasted or salted? vending machines?

___ Yes (1) ___ Never or very rarely (0)

___ No (0) ___ 1-2 times per week (2)
___ 3 times per week (5)
18. How often do you use white table ___ 3+ times per week (10)
sugar as a sweetener?
24. Do you drink tap water?
___ Never or very rarely (0)
___ once a week (1) ___ Yes (10)
___ 2-3 times per week (3) ___ No (0)
___ 3+ times per week (5)
25. How often do you eat some form
19. How often do you use artificial of store-bought dessert such as
sweeteners such as Sweet-n-Low, ice cream, cookies, donuts, cakes
Equal or NutraSweet? or pies?

___ Never or very rarely (0) ___ Never or very rarely (0)
___ once a week (1) ___ once a week (1)
___ 2-3 times per week (5) ___ 2-3 times per week (3)
___ 3+ times per week (10) ___ 3+ times per week (5)

Total Score: _____

30 How to Eat Move and Be Healthy!

 Stress 2

1. Do you eat more or less when 9. Do you feel stressed due to lack of
stressed than when not stressed? intimacy in one or more
relationships?
___ More (10)
___ Same or less (0) ___ Yes (5)
___ No (0)
2. Do you worry over job, income or
money problems? 10. Have you had reduced contact
with friends (feeling antisocial)
___ Yes (10) or an increase in contact because
___ No (0) you feel you need to vent your
frustrations or stresses to others?
3. Are any of your relationships
causing you stress? ___ Yes (3)
___ No (0)
___ Yes (10)
___ No (0) 11. Do you take any form of
medication prescribed by a
4. Do you often feel anxious? physician directly or indirectly
related to stress in your life or for
___ Yes (5) a psychological disorder?
___ No (0)
___ Yes (15)
5. Do you often get upset when ___ No (0)
things go wrong?
12. Do you commonly lose more than
___ Yes (5) two days of work a year due to
___ No (0) illness?

6. Do you lash out at others? ___ Yes (5)

___ No (0)
___ Yes (5)
___ No (0)
Total Score: _____
7. Do you feel your sex drive is lower
than normal for you?

___ Yes (5)

___ No (0)

8. Do you feel isolated or lonely?

___ Yes (3)

___ No (0)

Questionnaires 31
2 Sleep Wake Cycles
1. Do you live in the same time zone 7. Has your sense of hunger changed
you were born in? from being hungry at breakfast
(upon rising), lunch (midday) and
___ Yes (0) dinner times (sunset) since
___ No (5) moving to a new time zones
or traveling across time zones
2. Do you travel across time zones frequently (more than once a
more than once a month? month)?

___ Yes (10) ___ Yes (10)

___ No (0) ___ No (0)

3. How often do you wake up feeling 8. How often do you wake up at night
un-rested and in need of more between 1:00 a.m. and 4:00 a.m.
sleep? and have a hard time falling back
to sleep?
___ Never or very rarely (0)
___ once a week (1) ___ Never or very rarely (0)
___ 3 times per week (5) ___ once a week (1)
___ 3+ times per week (10) ___ 3 times per week (5)
___ 3+ times per week (10)
4. Do you commonly go to bed after
10:30 p.m.? 9. How often do you tend to have a
hard time staying awake in the
___ Yes (10) afternoon after eating lunch?
___ No (0)
___ Never or very rarely (0)
5. Are the times you have bowel ___ once a week (1)
movements consistent and ___ 3 times per week (5)
predictable on a daily basis? ___ 3+ times per week (10)

___ Yes (0) 10. Do you do shift work that requires

___ No (5) you to stay up late at night?

6. Do you suffer from reduced ___Yes (10)

memory since moving to a new ___ No (0)
time zone or since traveling across
time zones?
Total Score: _____
___ Yes (10)
___ No (0)

32 How to Eat Move and Be Healthy!

 You Are When You Eat 2

1. Do you frequently skip meals? 7. How often do you consume drinks

containing caffeine or sugar
___ Yes (3) (i.e. coffee, tea, sodas, fruit juices
___ No (0) with sucrose, corn syrup or added
sugar)?
2. How often do you typically go
more than four hours without ___ Never or very rarely (0)
eating? ___ 1 cup a day (1)
___ 2 cups per day (3)
___ Never or very rarely (0) ___ more than 2 cups per day (5)
___ 1-2 times per week (1)
___ 3 times per week (2) 8. Have you tried diets to lose weight?
___ 3+ times per week (3)
___ No (0)
3. How often do you skip breakfast? ___ once (1)
___ twice (2)
___ Never or very rarely (0) ___ 3-5 times (5)
___ 2 times per week (1) ___ more than five times (10)
___ 3 times per week (5)
___ 3+ times per week (10) 9. Do you have difficulty burning fat
around your belly, hips or thighs
4. Do you avoid fats when eating? even with regular exercise?

___ Yes (5) ___ Yes (3)

___ No (0) ___ No (0)

5. Do you frequently eat 10. Do you eat your largest meal in

carbohydrates (i.e. breads, bagels, the evening?
cookies, pasta, fruit, cereals,
muffins, crackers, chocolate, or ___ Yes (1)
candy) by themselves? ___ No (0)

___ Yes (5)

___ No (0) Total Score: _____

6. Do you often get hungry or crave

sweets within two hours after
eating a meal?

___ Yes (5)

___ No (0)

Questionnaires 33
2 Digestion
1. How often do you experience 7. How often do you have a poor
lower abdominal bloating? appetite or feel worse after
eating?
___ Never or very rarely (0)
___ 1-2 times per week (3) ___ Never or very rarely (0)
___ 3 times per week (5) ___ 1-2 times per week (3)
___ 3+ times per week (10) ___ 3 times per week (5)
___ more 3 times per week (10)
2. Do you frequently have loose
stools or diarrhea? 8. Do you have an excessive appetite
and/or sweet cravings?
___ No (0)
___ once a week (1) ___ Yes (5)
___ 3 or more times per week (5) ___ No (0)

3. How often do you experience 9. Do you frequently (more

constipation or stools that are than twice a week) experience
compact or hard to pass? abdominal pain, cramps or general
abdominal discomfort?
___ Never or very rarely (0)
___ 1-2 times per week (3) ___ Yes (20)
___ 3 or more times per week (5) ___ No (0)

4. Do you find that you often burp 10. How often do you have
after meals? indigestion, heartburn or an upset
stomach?
___ Yes (3)
___ No (0) ___ Never or very rarely (0)
___ 1-2 times per week (3)
5. Do you frequently have gas? ___ 3 times per week (5)
___ more 3 times per week (10)
___ Yes (3)
___ No (0) 11. How often do you get a headache
after eating?
6. Do you crave certain foods such
as bread, chocolate, certain fruit, ___ Never or very rarely (0)
and red meat if you have not ___ 1-2 times per week (3)
eaten them in a day or two? ___ 3+ times per week (5)

___ Yes (5)

___ No (0) Total Score: _____

34 How to Eat Move and Be Healthy!

 Fungus & Parasites 2

1. Have you ever been given general 8. Do you have two different kinds of
anesthesia? metal in your mouth; i.e., gold
and silver or mercury amalgam
___Yes (10) and gold or silver?
___No (0)
___Yes (5)
2. Have you ever taken antibiotics? ___No (0)

___Yes (10) 9. Do you experience itching in the

___No (0) ears, nose or rectum area?

3. Have you been or are you being ___Yes (10)

treated for any condition requiring ___No (0)
that you take medical drugs?
10. Do you have or have you had
___Yes (10) dandruff in the past year?
___No (0)
___Yes (10)
4. In general, are your bowel ___No (0)
movements loose, hard or foul
smelling? 11. Do you regularly eat or drink
products containing sugar, white
___Yes (10) flour, processed dairy products?
___No (0)
___Yes (5)
5. Would you consider your life to be: ___No (0)

___Stress free (0) 12. Do you crave sugar, fruit or milk

___Mildly stressful (5) if you don’t have either of these
___Very stressful (10) items for more than three days?

6. Do you currently suffer from any ___Yes (10)

digestive disorder or frequently ___No (0)
have pain in the region above or
below the navel? 13. Do you find that regardless of how
much you eat you get hungry
___Yes (10) quickly?
___No (0)
___Yes (5)
7. Do you have mercury amalgam ___No (0)
fillings in your mouth?

___Yes (10)
___No (0)

Questionnaires 35
2 14. In the past year, have you 18. Do you snack on sweets or drink
experienced athlete’s foot coffee, soda pop or sports drinks
(itching around the toes, soles most days to keep your energy
or heel of the feet), jock itch or a up?
fungal infection under a toenail
(thickening of the toenail)? ___Yes (10)
___No (0)
___Yes (20)
___No (0) 19. Do you suffer from any kind of
skin condition?
15. Do you ever get a reddening
around the mouth or nose area ___Yes (10)
after eating or drinking? ___No (0)

___Yes (5) 20. Have you ever had sex or close

___No (0) physical contact with anyone who
you know had a fungal infection
16. Do you experience muscle or joint (including athletes foot, jock itch,
aches on a regular basis? dandruff) or parasite infection?

___Yes (5) ___Yes (20)

___No (0) ___No (0)

17. Do you experience mood swings? Total Score: _____

___Yes (10)
___No (0) If you score high on this questionnaire,
refer to page 239 of the Appendix for
more information regarding fungi, par-
asites and the approach that you should
take.

36 How to Eat Move and Be Healthy!

 Score Chart
2

Sleep/Wake Cycles

Fungus & Parasites

Zones 1, 2 and 3

Zones 1, 2 and 3
You are When
You are What

Zones 3 and 4

Total Score
Digestion
(page 29)

(page 32)

(page 33)

(page 34)
You Eat

(page 35)
You Eat
(page 31)
Stress
Zone 4

Zone 3
130 81 90 50 81 195 627
High Priority

60 60 70 35 90 120 L

50 40 50 20 40 60 260
Moderate Priority

40 30 40 15 30 50 K

30 20 30 10 20 40 150
Low Priority

15 10 15 5 15 20 J

Score 1
Date:

Score 2
Date:

Name: __________________________

Score your graph automatically when you complete the CHI Questionnaires
online at www.eatmoveandbehealthy.com

Questionnaires 37
We hope you enjoyed this excerpt from

How to Eat, Move and Be

Healthy! by Paul Chek. If you would
like to read more, order the book from

the C.H.E.K Institute, 800.552.8789

(int’l ph: +1.760.477.2620) or on-line at

www.chekinstitute.com.

It is also available at

www.amazon.com,

www.barnesandnoble.com

and select bookstores.