WELCOME
Congratulations on taking the first step on this journey to achieving optimum health and overall well-being.
PERSONAL HEALTH ASSESSMENT QUESTIONNAIRE
Date
*
-
Month
-
Day
Year
Date
Q1 * WHICH OF THESE AREAS COULD YOU USE SUPPORT WITH (Select all applied)
*
Weight Loss
Energy, Performance & Strength
Anti-Aging, Sleep & Restorative Health
Digestive Health & Immune System Support
Nutrition & Cleansing
Accountability & Mindset
Brain Health & Body Balance
Q2 * WHICH DESCRIBES YOUR MIND & BRAIN FUNCTION?
*
I feel tired and slow all the time
I feel foggy and confused at times
I feel periods of clarity with moments of mental exhaustion
I feel clear but desire to support brain health
Q3 * RATE YOUR ENERGY LEVEL
*
I have low energy
I have energy if I keep going, but crash when I stop
My energy level is good, but could be better
I have energy all the time
I have good energy and want to maintain it as I age
Q4 * ARE YOU AT YOUR IDEAL WEIGHT?
*
I want to lose 5-20 pounds
I want to lose 21-50 pounds
I want to lose 50-100 pounds
I want to lose over 100 pounds
I need to gain weight
My weight is good, but I want to maintain it
Q5 * HAVE YOU DONE A CLEANSE?
*
Never
Once
Multiple Times
Q6 * WHAT ARE YOUR EATING HABITS?
*
I eat healthy
I try to eat healthy, but binge on sweets/junk food
Healthy, but not getting adequate protein and nutrients
Q7 * DO YOU HAVE MUSCLE WEAKNESS OR JOINT PAIN?
*
Yes
No
Q8 * ARE YOU EQUIVALENT TO YOUR AGE?
*
I look and feel older than my age
I look and feel my age
I look and feel younger than my age
Q9 * HOW OFTEN DO YOU CONSUME ALCOHOL?
*
Daily
Weekly
Monthly
Occasionally
Never
Q10 * DO YOU HAVE CHOLESTEROL ISSUES?
*
Yes
No
Q11 * DO YOU TAKE DAILY VITAMINS?
*
Yes
No
Q12 * DO YOU TAKE ANY MEDICATIONS?
*
Yes
No
Q13 * WHAT IS YOUR ACTIVITY LEVEL
*
I exercise 5 or more times a week
I exercise 3 or more times a week
I try to exercise, but have no consistency
I do not exercise, but need to
Q14 * RATE YOUR STRESS LEVEL?
*
High
Moderate
Low
Calm & Balanced
Q15 * DO YOU SET GOALS AND DO YOU ACHIEVE THEM?
*
Never
Sometimes
Always
Q16 * RATE HOW IMPORTANT YOUR HEALTH IS TO YOU?
*
Very Important
Somewhat Important
Not That Important
HOW CAN WE GET IN TOUCH WITH YOU?
Name
First Name
Last Name
WHAT IS YOUR PREFERRED METHOD OF CONTACT?
TEXT
PHONE
EMAIL
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Thank you!
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