Confidential Lifestyle Assessment
TO KNOW WHERE YOU ARE GOING, YOU MUST KNOW WHERE YOU ARE AT
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Height
Weight
Ideal Weight
What is your blood type?
O
A
B
AB
I don't know
Are you happy with you energy levels and how do you feel day to day?
Yes, extremely happy
Yes, happy
sometime yes, sometimes no
Not very happy. I need improvement
Very disappointed, something needs to change immediately
Please elaborate further if you would like to
Are you happy with how your body looks?
Yes, extremely happy
Yes, happy
sometime yes, sometimes no
Not very happy, I need improvements
Very disappointed, something needs to change immediately
Please elaborate further if you would like to
Check the conditions that apply to you:
Asthma
Excessive Menstral Cramping
Cardiac Disease
Hypertension
Digestion Issues
High Cholesterol
Excema / Psoriasis
Drug Addiction
MS
Sleep Apnea
Headaches
Poor Blood Circulation
Acne
Menstrual Irregularities
Cancer
Diabetes
Stress / Anxiety
Obesity
Constipation
Alcohol Addiction
ALS
Insomnia
Acid Reflux
Diarrhea
Parkinson's
Neuropathy
PTSD
Arthritis
COPD
Chrone's Disease
Colitis
Diverticulitis
IBS
Lupus
If you have been diagnosed with a specific disease or condition please elaborate.
Check the symptoms that you are currently experiencing:
None
Respiratory
Cardiovascular
Hematological
Lymphatic
Psychiatric
Weight Gain
Weight Loss
Musculoskeletal
Fatigue
Can't lose weight
Bowel Discomfort
Hand weakness
Slurred Speech
ED
Low or Loss Libido
Chest Pain
Other
Do you have family history of chronic disease? (please list family member and condition)
Check the following physical activities that you have engaged in at least once in the last two weeks:
None
Walking Outside 30+ minutes
Cycling
Calisthenics
Yoga
Swimming
Tennis
Cardio Training
Jogging
Pilates
Crossfit
HIT Training
Hiking
Core Work / Abs
Physical Therapy
Weight Training
Golf
Other
Check the following mental activities that you engage in at least once per week:
None
Self Meditation
Guided Meditation
Therapy
Counciling
Prayer
Attend Church
Singing
Dancing
Reading
Charity Work
Other
How much sleep do you average per night?
Please Select
Less than 4
5
6
7
8
9 or more
How many times per week to have bowel movements?
Please Select
1
2
3
4
5
6
7
8 or more
Have you noticed any changes in your bowel movement cycles or and bleeding?
Please Select
Yes
No
If Yes, please elaborate
Have you had a physical in the last 12 months?
Please Select
Yes
No
What are your hobbies and interests? (please list as many as possible)
Do you suffer from or have you ever suffered from any of the following?
Depression
Post Partum Depression
Lonliness
Anxiety
Stress
Bipolar Disorder
Performance Anxiety
Burn Out
Suicidal Thoughts
Please check if you excessively perform any of the following for more than 10-12 hours per week
Watching TV
Playing Video Games
Consuming Social Media
Gossiping
Complaining
Worrying
Have you had a colonoscopy in the last 2 years?
Please Select
Yes
No
Are you color blind?
Please Select
Yes
No
Are you currently taking and pharmaceutical prescriptions or over the counter medications?
Yes
No
If Yes, please list them with daily dosage
Have you taken an ALCAT or food allergy / food sensitivity test?
Yes
No
Not sure
Do you consume junk food? (candy, chocolate, sugars, potato chips etc)
Please Select
Yes
No
Do you consume dairy products? (milk, cheese, butter, yogurt, mayo, creamers)
Please Select
Yes
No
What meat products do you consume?
Beef
Pork
Chicken
Eggs
Ham
Bacon
Fish
Sausage
Deli Meats
Turkey
How many cups of coffee do you drink per day?
Please Select
0
1
2
3
More than 3
Do you drink soda, sports or energy drinks?
Please Select
Yes
No
Have you ever used cannabis?
Please Select
Yes
No
Have you ever used CBD products?
Please Select
Yes
No
How many ounces of water do you drink?
Please Select
Less than 20 ounces
21-40 ounces
41-60 ounces
61-80 ounces
80-100 ounces
101-120 ounces
More than 121 ounces
Do you or have you used any form of tobacco products in the last 5 years? (cigarettes, cigars, pipes, chew or dip, vape pens)
Please Select
Yes
No
Yes but longer than 5 years ago
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Please list your typical ingredients for BREAKFAST.
Please list your typical ingredients for LUNCH.
Please list your typical ingredients for DINNER.
Please typical things you snack on throughout the day.
How would you rate your overall health?
Very Healthy
Healthy
Moderately Healthy
I need to do better
I'm unhealthy
How would you describe your midsection and abdominal area?
Toned or flat stomach
Slightly bloated
Slight belly fat
Excessive belly fat
Is there any other information that you would like our team to know that can better help us serve you?
Are you married or do you have a significant other
Yes
No
If Yes, what is your spouse or partner's name?
Do you have children? (child or adult age)
Yes
No
Please list names and ages of your children
Do any of your family members and/or friends that may also need some help or guidance to better improve their health and lifestyle?
Submit
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