Congratulations on taking the first step on this journey to achieving optimum health and overall well-being.
PERSONAL HEALTH ASSESSMENT QUESTIONNAIRE
Q1 * WHICH OF THESE AREAS COULD YOU USE SUPPORT WITH (Select all applied)
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?
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?
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?
Q10 * DO YOU HAVE CHOLESTEROL ISSUES?
Q11 * DO YOU TAKE DAILY VITAMINS?
Q12 * DO YOU TAKE ANY MEDICATIONS?
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?
Calm & Balanced
Q15 * DO YOU SET GOALS AND DO YOU ACHIEVE THEM?
Q16 * RATE HOW IMPORTANT YOUR HEALTH IS TO YOU?
Not That Important
HOW CAN WE GET IN TOUCH WITH YOU?
WHAT IS YOUR PREFERRED METHOD OF CONTACT?
Street Address Line 2
State / Province
Postal / Zip Code
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