Number of Yes'
Do you smoke (ANYTHING)?
*
Yes
No
Do you exercise less than 3 days each week?
*
Yes
No
Do you have moderate or more levels of stress at work?
*
Yes
No
Do you have moderate or more levels of stress at home?
*
Yes
No
Do you have any kids under the age of 4?
*
Yes
No
Do you ever get shortness of breath?
*
Yes
No
Do you eat organic foods?
*
Yes
No
Do you have fish at least twice a month?
*
Yes
No
Do you have cereal twice a week?
*
Yes
No
Do you have a family history of heart disease?
*
Yes
No
Do you have diabetes?
*
Yes
No
Are you on any medications?
*
Yes
No
Have you ever had heart burn?
*
Yes
No
Have you taken anything EVER for heart burn?
*
Yes
No
Do you experience any left arm pain?
*
Yes
No
Have you had chest pain?
*
Yes
No
Have you had stroke or been told you have TIAs?
*
Yes
No
Are your cholesterol and/or Tri-Glyceride numbers outside recommended range?
*
Yes
No
Have you ever had any root canals or any extractions?
*
Yes
No
Have you ever had an infection in your gums or teeth?
*
Yes
No
Do you eat sugar at least 3 times a week? Ex. Candy, chocolate, soda, etc.
*
Yes
No
Do you eat fast food at least 1 twice a week?
*
Yes
No
Do you take aspirin once a week?
*
Yes
No
Do you have 2 or more cups of coffee a week?
*
Yes
No
Do you have low energy?
*
Yes
No
Have you ever had the flu?
*
Yes
No
Have you ever had depression?
*
Yes
No
Have you ever had Chemotherapy?
*
Yes
No
Have you ever had Any Types or Forms of Cancers or Tumors?
*
Yes
No
Are you on ANY natural or prescribed hormone replacement therapy?
*
Yes
No
Do you do anything for fun daily?
*
Yes
No
Do you take less than 2 vacations a year?
*
Yes
No
Do you consume alcohol twice or more a week?
*
Yes
No
Do you eat fried food at least once a week?
*
Yes
No
Do you have neck problems?
*
Yes
No
Do you have chronic headaches or migraines?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Have you had any heart attacks or surgery concerning the heart or circulation?
*
Yes
No
Do you experience any tingling or numbness?
*
Yes
No
Name
*
First Name
Last Name
Email
*
example@example.com
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Phone Number
*
-
Area Code
Phone Number
Submit
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