Spheric Health Self Assessment
By completing this form you are granting Spheric Health permission to email you information about our program. Completing the medical questionnaire is voluntary and will enable a tailored recommendation but is not required. Thank you.
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Email *
Name *
Age *
How would you describe your personal environment?
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How many hours do you sleep per day?
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What is your bowel activity/frequency- on average?
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Briefly describe your top three health goals
Rank from 1 (none/never) to 4 (always/severe)
One
Two
Three
Four
Not applicable
Unexplained weight loss
Weight gain belly/midsection
Change in appetite
Fatigue
Cold hands or feet
Vision changes
Ringing in ears
Frequent runny nose
Sinus Pain
Shortness of breath
Swelling
Frequent heartburn
Frequent bloating
Frequent constipation
Frequent loose stools
Hot flashes / sweating
Tingling in hands or feet
Headaches
Increased difficulty with memory
Loss of balance
Brain fog
Mood swings
Aching / painful joints
Clear selection
Diagnosed medical conditions, Known allergies, or intolerances to medication, food, environmental factors.
Any other information you would like to share?
Submit
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