Please fill out the form as accurately as possible.
1. Please select the following categories of medications that you are currently prescribed and/or taking over the counter:
2. Please select any supplements that you are currently taking:
3. Please List Any Prescriptions or Other supplements:
4. Energy Goals: "I'd like to..."
Have more energy and longer endurance
Have more motivation
Be less tired
Get less colds and flu
Get rid of allergies
Stop using laxatives
Be free of pain
5. Longevity Goals "I'd like to..."
Reduce my risk of degenerative disease
Slow down my accelerated aging
Monitor biomarkers of aging
Change from "treating illness" orientation to creating a wellness lifestyle
6. Body Composition Goals "I'd like to..."
Be more flexible
7. Stress Reduction Goals "I'd like to..."
Be less moody
Be more focused
Improve my memory
Learn how to reduce stress
Learn how to meditate
8. Are you interested in jump starting your goals? A 10 or 30 day cleansing program will be a great way to improve weight loss and energy levels. Are you interested?
9. Food: check all of the following that apply.
Occasionally or frequently skipped meals
Crave sweets or carbohydrates
Crave stimulants such as coffee/tea/soda
Suffer from chronic pain
Suffer from headaches
Use artificial sweeteners/diet drinks or diet products
Eat fast food/ fried foods
10. Balanced Eating- check all of the following that apply.
Mixed food diet (animal & vegetable)
The Zone Diet
Total calorie restriction
11. Eating frequency- check the following that apply.
Skip breakfast or other meals
Eat 4+ meals a day
Eat 2 to 3 meals a day
Eat 1 meal a day
Graze throughout the day
Generally eat on the run
Eat fruits every day
Eat vegetables every day
Eat at least one salad per day
12. Activity level:
Level 1 - Very light work: sitting standing, driving, reading, computer
Level 2 - Light work: light house-work, labor, childcare, mechanic, some sitting
Level 3 - Moderate work: heavy gardening, housework, labor, no sitting
Level 4 - Heavy work: heavy manual labor, construction, digging
13. Exercise frequency and schedule:
0-2 days a week working out
3-5 days a week working out
6-7 days a week working out
Use of personal trainer
Member of a fitness club
Own exercise equipment
14. Digestion: do you experience any of the following?
15. How many bowel movements do you have per day?
3 or more
16. Do you use any of the following stimulants?
17. If you selected any of the above, please tell us how much each is used per day/week?
18. How many cups (8 oz) of water do you drink a day?
19. On a scale 1 to 10 (1 being the lowest, 10 being the highest), what level of stress are you experiencing?
20. How many hours of sleep do you average per night?
21. Are you able to fall asleep?
22. Do you suffer from insomnia or sleep disorders?
23. Do you remember your dreams?
24. Do you sleep with any electronic devices on (including light, tv, radio, computer, etc)?
25. Do you often abruptly awake from sleep?
26. Do you suffer from depression or mood swings?
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