AWA - Health Assessment

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A Wellness Alternative 5-Minute Health Assessment

Please answer these questions carefully and then schedule your Health Advantage Consultation! Your answers are 100% confidential and will help us determine how to best help you reclaim your health.

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1. Select any of the following medications you are taking:
Antacids
Antibiotics/Antifungal
Antidepressants
Anti-inflammatories
Sleeping pills
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2. Select any of the following if you are suffering from:
Bloating
Constipation
Food allergies
Dry, flaky skin, dry brittle hair
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3. Select any of the following if you are suffering from:
Sour taste in the mouth
Bad breath
Swollen eyes (bulging)
Sensitive to the cold
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4. Select any of the following if you are suffering from:
Cannot tolerate much exercise
Depression or rapid mood swings
Lack of mental alertness
Catch colds easily when weather changes
Headaches / Migraines
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5. Select any of the following if you are suffering from:
Heaviness in legs
Calf muscles cramp while walking
Heart pounds easily or misses heartbeat
Dizziness, vertigo
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6. Select any of the following if you are suffering from:
Crave sweets
Need to drink coffee to get started
Poor memory
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7. Select any of the following if you are suffering from:
Difficulty breathing
Smoking
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8. Select any of the following if you are suffering from:
Frequent urination OR can’t hold urine
Frequent bladder infections
Difficulty passing urine
Dripping after urination
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9. (MALES ONLY) Select any of the following if you are suffering from:
Increased straining with smaller and smaller amounts of urine passed
Lack of sex drive
Difficulty attaining or maintaining an erection
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10. (FEMALES ONLY) Select any of the following if you are suffering from:
Depression / Anxiety /Moodiness / irritability
Low or no desire for sex
Disorders with menstrual cycle
Hot flashes / night sweats
Painful intercourse
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11. Select any of the following if you are suffering from:
Arthritis or joint pain
Drink carbonated beverages
Muscle spasms / cramps
Pain in neck, shoulders, or back
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12. Select any of the following if you are suffering from:
Head feels heavy
Lightheadedness/fainting
Loss of balance
Ringing/buzzing in ears
Trembling hands
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13. Select any of the following if you are suffering from:
Can’t fall asleep
Wake up in the middle of night, can’t fall back to sleep
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Please enter your full name* This field is required.
First Name
Last Name
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Please enter your email* This field is required.
example@example.com
Should be Empty:

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