Health Assessment

1
Overall, how would you describe your current state of health?After answering this question, the assessment will guide you through evaluating various aspects of health, including lifestyle, symptoms, and desired health goals.
Huge
Large
Normal
Small
Ok
Ok
2
What is your age range?
18-29
30-39
40-50
0ver 50
3
Do you get hungry or tired before lunch?
Yes
No
4
Do you get hungry or tired in the afternoon?
Yes
No
5
How many hours of sleep do you typically get each night?
Less than 4
5-7
8+
6
Rate your current level of stress:Scale/description 0-10
Stress
Not at all stressed (0-1)
Low-level stress sometimes (2-4)
Feeling stress most days (5-7)
High stress most of the time (8-9)
Extreme high stress (10)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Stress
Not at all stressed (0-1)
Low-level stress sometimes (2-4)
Feeling stress most days (5-7)
High stress most of the time (8-9)
Extreme high stress (10)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
7
How much water do you drink daily?
Less than 8 ounces
1-2 glasses of water (8-16 oz)
3-4 glasses of water (24-32 oz)
5-6 glasses of water (40-48 oz)
7-8 glasses of water (56-64 oz)
9-10 glasses of water (72-80 oz)
100+ ounces
8
What will you choose when you want to drink something other than water?Select all that apply.
Green tea
Black tea
Coffee
Juice
Carbonated water
Soft drinks / soda
Flavored water
Electrolyte drink
Alcohol
9
How often do you exercise?
Never
1-2 times a week
3-4 times a week
5-7 times a week
Other
10
How would you describe your current WEIGHT?
Under weight
Overweight
At ideal weight
11
What weight-related goals do you want to achieve?Select all that apply.
Weight loss
Fat loss
Weight maintenance
Build lean muscle mass
Weight gain
12
If you have a weight loss goal, about how many pounds would you ideally like to lose?
under 10 pounds
10-20 pounds
20-30 pounds
30-50 pounds
Over 50 pounds
13
Do you have any DIAGNOSED health conditions? If so, please list them here (including medications, if applicable)
14
What health areas are you interested in?Select all that apply.
Weight management
Nutrition
Digestive health
Immune support
Energy
Focus and vitality
Healthy aging
Athletic performance
Pain management
Recovery
15
What SYMPTOMS do you struggle with?Select all that apply.
Sugar/food cravings
Headaches/migraines
Brain fog/trouble thinking clearly
Difficulty sleeping
Weight management
Belly fat
Food sensitivities (gluten, dairy)
Allergies (seasonal)
Autoimmune disorder (diagnosed)
Chronic pain
Digestive issues (acid reflux, GERD)
PMS (mood, cramps, headache)
Menopause symptoms (hot flashes, night sweats, heightened emotions, etc.)
IBS or constipation
Anxiety
Bloating
Weak nails/hair loss
Hormone balance/issues
Blood sugar issues/balance
Low energy
Insulin resistance
Mood issues (depression, feeling low)
Blood pressure (high)
Cholesterol (high)
Aging skin
Inflammation
Focus
Joint pain
Chronic fatigue
"Puffiness" in face
16
What are your TOP PRIORITY health issues to solve?It is typical to have multiple health needs or priorities. However, what 1-3 things would you like to tackle first? Think about answering: "If I could solve _____, it would make a huge difference to me!"
17
Do you currently use natural health supplements?
Yes
No
I have in the past, but not now
18
What health supplements do you currently take (if any)?
19
What is your last known blood pressure reading?
20
What is your last known fasting blood sugar/glucose number?
21
What is your last known triglyceride number?
22
What is your last known HDL cholesterol number?
23
What is your last known LDL cholesterol number?
24
What is your current waist circumference?[Measure around the largest part of your belly.]
25
Would you like to know more about how I can help you with your goals by making a few small changes?
Yes
No
Maybe
26
Do you enjoy helping other people find solutions to their health issues and sharing what you know?
Yes
No
Sometimes
27
Name* This field is required.
First Name
Last Name
28
Email* This field is required.
example@example.com
29
Phone* This field is required.
example@example.com
30
In response to submitting this form, you are giving permission to be contacted regarding your assessment responses with:

a list of specific products, programs, or recommendations that will help you, based on the information you provide

an invitation to connect with me personally

a request for additional information, if necessary

[The content on this site is for informational purposes only and is not medical advice. The information provided is for informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen.]
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