Health Check Evaluation

HEALTH EVALUATION

The following questionnaire is a comprehensive look at your health. It will take about 5 minutes to complete
Full Name

First Name Last Name
Gender

Male Female
What are your main health concerns? *

Weight loss Detox Disease Prevention Pre-conception & Pregnancy Care Digestive Support Cardiovascular Protection Stress Management Dietary Advice Energy Immune System Sports Enhancement Pain Management Other
YOUR GENERAL HEALTH EVALUATION

Please rate yourself from 1 - 10 (1=poor / 10=excellent)for the following questions. Where are you at as of today?
Please rate yourself from 1 - 10 (1=poor / 10=excellent)

for the following questions.
How do you rate your current level of health? *
How do you rate your daily intake of water? *
How do you rate your level of daily exercise? *
Based on 7 days a week, how would you rate your nutritional lifestyle? *
How would you rate your level of stress? (0=Not Managed, 5=Sometimes Managed, or 10= Always managed) *
Overall, do you practice cleansing on a regular basis? (0= No, 5= Sometimes or 10= regularly) *
Overall, how well do you sleep? *
How would you rate your unhealthy habits? (0=Not Managed, 5=Sometimes Managed, or 10= Always managed) *
Do you have any current health concerns?
Additional info you might want to share:
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HEALTH EVALUATION

YOUR GENERAL HEALTH EVALUATION