Assess Your Health Health Assessment Questionnaire Name * First Last Email * Age * Weight * Gender * Height * How many hours of sleep do you get each night, on AVERAGE? * Less than 4 hours each night Between 4 and 6 hours each night More than 6 hours each night More than 8 hours each night How would you rate your stress level? * I am stressed during my entire day I am stressed only when at work I am stressed only when at home I am stressed a few times a week I rarely feel stressed How often are you consuming alcohol? * 2 or more drinks per day 5 or 6 drinks per week Once or twice a week Once or twice a month A few times a year I never drink How often do you exercise? * Every day Every other day Less than two times a week Once a week Couple of times a month I rarely exercise How often do you eat breakfast? * Every Day 3 or 4 times per week Once or twice a week Rarely Never How many servings of vegetables and fruits do you eat each day? Do not include potatoes of any type. * 5 or more per day 3 to 4 per day 1 or 2 per day I rarely eat fruits or vegetables How often do you consume food from a restaurant either dining in or out? * At least once a day 2 or 3 times per week More than 4 times per week Every day at least once Do you smoke? * Never have Used to but I quit Yes, I currently smoke Do you take any supplements? * Yes No If so, please describe the types of supplements you are taking and how often. * Please describe your health issue(s) in detail below. * Submit
