Questionnaire | Be Healthy As Can Be

Name *

E-mail *

Home Phone

Business Number

Birth Year *

What kind of degenerative diseases run in your family? *

Cancer

Heart Disease

Diabetes

Arthritis

Other

About how many colds do you have a year? * *

0 - 1 per year

1 - 2 per year

3 - 4 per year

More

How's your digestion? *

Heart Burn

Belching

Gas

Constipation

Okay

Have you ever taken antibiotics? *

Yes

No

If Yes, please explain

Cholesterol *

High

Normal

Low

Blood Pressure *

High

Normal

Low

Do you use any medication? *

Yes

No

If Yes, please explain

Are you tired much? *

Morning

Evening

After Meals

Infrequently

All the time

Are you tired much? (1 wiped out - 10 dynamo) *

1

2

3

4

5

6

7

8

9

10

How well do you eat? *

Excellent

Good

Poor

Do you eat out much? *

Daily

Weekly

Monthly

Do you drink coffee? *

Yes

No

If Yes, please explain how much

Do you smoke? *

Yes

No

If Yes, please explain how much

Do you drink? *

Yes

No

If Yes, please explain how much

Please describe your exercise routine including how long and how often. *

Please describe any Supplements you use and if they helped. *

What would you like to improve or achieve in relation to your health? *

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