Assess Your Health

Health Assessment Questionnaire

"*" indicates required fields

Name*

First Last

Email*

Age*

Weight*

Height*

Gender*

How many hours of sleep do you get each night, on AVERAGE?*

How would you rate your stress level?*

How often are you consuming alcohol?*

How often do you exercise?*

How often do you eat breakfast?*

How many servings of vegetables and fruits do you eat each day?*

Do not include potatoes of any type.

How often do you consume food from a restaurant either dining in or out?*

Do you smoke?*

Do you take any supplements?*

If so, please describe the types of supplements you are taking and how often.*

Please describe your health issue(s) in detail below.*

Name

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