Risk Factors Survey
How strong is your immunity? Find out how at risk you are and what you need to do to meet your fitness and vitality goals. >>Get on your best path for your most optimal health and fitness. >>Bullet proof your immune system. >>Immediately develop your desired habits and lifestyle rituals. Fill out this survey as carefully and completely as possible. We will reply back within 48 hours with your system.
1. Name
*
First Name
Last Name
Email
*
example@example.com
2. Height
3. Weight
4. Age
5. What is your resting heart rate? Check before you get out of bed.
6. How many times per year do you get sick? Explain with detail.
7. How many headaches do you have per week and rate from 1- 10 their severity, 1 being the least severe.
8. Do you consider yourself an optimistic or pessimistic person? Why?
9. What is your blood pressure reading, both the top and bottom numbers? (I need your most current reading)?
10. What is your total cholesterol number?
11. What is your good cholesterol number (HDL)?
12. What is your bad cholesterol number (LDL)?
13. Does your normal anxiety negatively interfere with daily functioning?
14. Do you live alone?
15. How many times per week do you exercise?
16. What kind of exercise do you do? Resistance or no resistance?
17. Generally, how is your energy level? Rate from 1-10, 10 is considered highest.
18. Do you consider yourself a leader? Explain why.
19. Do you consider yourself a follower? Explain why.
20. Do you eat more fast food or home cooked meals?
21. Do you have any underlying health conditions, including and not limited to asthma, diabetes, high blood pressure, lung disease, congestive heart failure, heart disease, strokes? Please explain.
22. What kind of medication are you taking?
23. What kind of supplements are you taking?
24. Do you have circulation issues?
25. How often do you get your full panel lipid blood work done?
26. How many hours a night do you sleep?
27. Are you chronically stressed out? Explain with detail.
28. Are you excited about life?
29. Are you diabetic? If yes, Type 1 or 2?
30. Are you experiencing menopause? If question does not apply put N/A.
31. When was the last time you had a period? If question dos not apply put N/A.
32. How is your libido? Low, average, high?
33. Do you have skin conditions? Explain.
34. Do you have problems with constipation?
35. Do you have issues with bloating? How often?
36. Do have issues with dehydration? Explain.
37. Please list any additional information you think that has positive and negative impact on your life, with an explanation as to why.
38. Give me an example of what you eat in a day during the week and be as detailed as possible about the amount, including drinks (Ex: 4oz, a cup, a bowl).
39. Give me an example of what you eat in a day during the WEEKEND and be as detailed as possible with the amount, including drinks (Ex: 4oz, a cup, a bowl, large, 2 pieces).
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