My Personal Health Assessment
This personal health assessment will provide the information needed to identify best opportunities to improve your health.
Email address *
Your Name
Your answer
Do you often wake up feeling tired?
Do you have trouble going to sleep or sleeping through the night?
Do you regularly experience fatigue during the day?
What time do you go to bed?
Time
:
What time do you get up in the morning?
Time
:
What time do you eat breakfast?
Time
:
Number of meals/snacks per day
Your answer
Number of fruit servings/day
Your answer
Number of vegetable servings/day
Your answer
Number of ounces of water/day
Your answer
Number of days of physical activity/week
Your answer
Do you suffer from frequent headaches or migraines?
Do you experience lack of mental clarity or memory loss?
Do you have problems with digestion/gastrointestinal issues?
Do you have constipation on a regular basis?
Do you have asthma or allergies?
Do you frequently get colds, sinus congestion, flu-like symptoms?
Do you experience bouts of depression or anxiety?
Do you have arthritis?
Do you suffer from autoimmune disorders?
Do your joints hurt?
Are you experiencing menopausal symptoms?
Do you frequently experience food cravings?
Do you frequently eat when you are not hungry?
What is your stress level (1-10, 10 is highest)
Are you taking over the counter medications regularly?
Are you taking prescription drugs?
Your Height (Feet/Inches)
Your answer
Your Weight (Feet/Inches)
Your answer
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