Please spend at least a minute to complete your health assessment form for us to provide you with an individualized program
First Name
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Last Name
*
Email
*
Phone
*
Date of birth
*
Gender
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Male
Female
What are your fitness goals?
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Loose weight or body fat
Gain muscle
Improve balance
Manage a chronic health condition
Competitive body building
Better cardiovascular health
Others
Do you have trouble with any of the following?
Carrying a 10lb bag
Home chores like washing windows, vacuuming, mopping, etc.
Walking without assistance
Opening a jar of food
Climbing a flight of stairs
Others
Do you currently have or had pains in your shoulders, back, neck, hips, ankles, etc?
How many hours do you engage in physical activity per week?
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How often do you engage in physical activity?
0
1 - 2 hours a week
3 - 4 hours a week
5 - 7 hours a week
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Is there any reason why you feel you should not do physical activity?
Does your current occupation require any of these?
Long periods of sitting or standing
Long periods of repetitive tasks
Have you had any surgeries? If so, please explain.
What is your current weight?
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What is your height?
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Please list all the vitamins or supplements you are currently taking
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Please list all prescription or non-prescription medications you are currently taking. Put NONE if does not apply
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Do you have a father, mother, brother, or sister, with issues of diabetes, cancer, heart disease, stroke, etc?
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Yes
No
Do you frequently have health-related issues like high blood pressure or others with significant risks?
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Yes
No
Check The Following Symptoms That You Are Currently Experiencing
COGNITION
Poor memory or ability to recall
Poor physical coordination
Poor concentration
Poor comprehension
DIGESTIVE TRACT
Bloated feeling
Constipation
Intestinal/stomach pain
Heartburn
WEIGHT
Excessive weight
Underweight
Binge eating and drinking/compulsive eating/food addictions
Craving certain foods
ENERGY/SLEEP
Apathy, lethargy
Fatigue, sluggishness
Sleep disturbances
Hyperactivity
Restlessness, achiness
HEART
Rapid or pounding heartbeat
Irregular or skipped heartbeat
Chest pain
HORMONAL DISTURBANCES
Frequent or urgent urination
Genital itch or discharge
Frequent illness
Loss in libido?
Do you develop symptoms upon acute exposure to fragrances, exhaust fumes, or strong odors? *
Yes/No
Yes
No
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Do you currently use tobacco products or have you used them in the last 6 months?
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Yes/No
Yes
No
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Do you currently drink alcoholic beverages? If Yes, on average how much?
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Choose below
No
Less than 5 per week
1-2 a day
3 or more a day
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Do you drink caffeinated products? If Yes, how much?
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Choose below
No
Less than 5 per week
1-2 a day
3 or more a day
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If you have any known food allergies or food sensitivities, please list below.
*
Do you follow any specific diets or are there specific foods you do not eat. (Ex. Vegetarian no red meat). Put NONE if does not apply.
Do you get fatigued, drowsy, or experience brain fog frequently? *
Yes/No
Yes
No
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Have you ever or are you currently taking any hormone medications?
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Yes/No
Yes
No
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If yes, please choose from the list below:
Birth control
estradiol
progesterone
testosterone
dhea
Check the box if you have a personal history of any of these
Alcohol or chemical dependence
Environmental and/or chemical sensitivities
Chronic fatigue syndrome
Multiple chemical sensitivity
Fibromyalgia
Asthma
If you have any known food allergies or food sensitivities, please list here:
What have you tried in the past that did and didn't work?
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What are you currently trying to do to improve your health, if anything?
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On a scale of 1 - 10 (1 not at all, 10 absolutely 100% ready) Is this something that you are ready to start working to improve today?
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