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Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Business Name
(Required)
Age
(Required)
Biological Gender
(Required)
Male
Female
Height (ft)
(Required)
Height (in)
(Required)
Weight (lbs)
(Required)
How muscular are you?
(Required)
Not Very
Average
Above Average
Very Muscular
What best describes your blood pressure?
(Required)
Low Blood
Normal (110-120/70-80)
Mildly Elevated
Moderately Elevated (140/90 to 150/95)
Greater than 150/95
What is your resting heart rate?
(Required)
<50 (non-athlete)
<50 (athlete)
50-70 (non-athlete)
50-70 (athlete)
60-80
>80
>90
>100
Don’t Know (runs high)
Don’t Know (runs low)
How frequently do you exercise? (eg. >5000 steps per day, aerobic work out, workout of 30 minutes or more)
(Required)
Daily
2 to 3 times a week
1 time a week
1 time every 2 weeks
Rarely
How would you describe your diet?
(Required)
Average Americanized Diet
Mediterranean Diet
Love my Simple Carbs
Vegetarian (Veggie Centric)
Vegan
Paleo Diet
Keto Diet
How many (8 ounce) servings of caffeine do you consume daily?
(Required)
None
1
2-3
4-5
5+
How many regular sized meals do you consume per day (with sufficient calories to sustain your lean body mass)?
(Required)
1 Time
2 Times
3-4 Times
More than 4 times a day
How many servings of Carbs (noodles, bread, potatoes, rice, fruit, etc.) do you eat per day (serving is 1 cup volume)?
(Required)
0 Servings per day
1-2 Servings per day
3-4 Servings per day
5+ Servings per day
How many dessert or candy items do you consume per day (serving less than 150 calories)?
(Required)
0 Servings per day
1 Serving per day
2 Servings per day
3-4 Servings per day
5+ Servings per day
How many ounces of fruit juice do you consume daily?
(Required)
None
1 to 4 ounces
4 to 8 Ounces
8 to 12 Ounces
12 to 16 Ounces
How often do you consume fish/seafood, fish oil or omega-3 supplements per week?
(Required)
Never
Once per week
Twice per week
More than twice per week
How many pieces of fresh fruit do you consume daily (exclude bananas in your count)?
(Required)
Never
1-2 Servings per day
3-4 Servings per day
5+ Servings per day
How many ounces of regular soda do you consume daily?
(Required)
None
6-12 Ounces
12-20 Ounces
20-32 Ounces
32 Ounces or more
How many ounces of artificial soda or beverages due you consume daily?
(Required)
None
6-12 Ounces
12-20 Ounces
20-32 Ounces
32 Ounces or more
How many ounces of distilled spirits do you drink weekly?
(Required)
None
1 to 2 Ounces
3 to 4 Ounces
4 to 8 Ounces
8 to 16 Ounces
16 + Ounces
How many ounces of beer do you drink weekly?
(Required)
None
12 Ounces
12-24 Ounces
24-36 Ounces
36-60 Ounces
60-96 Ounces
96 Ounces or more
How many ounces of wine or wine coolers do you drink weekly?
(Required)
None
6 Ounces
6-12 Ounces
12-24 Ounces
24-32 Ounces
32 Ounces or more
Do you feel refreshed when you awaken?
(Required)
Yes
Half the time
No
Do you need a caffeinated beverage to feel awake in the morning?
(Required)
Yes
No
Do you have “drops in energy” before lunch or mid-afternoon?
(Required)
Never
At least two times a week
Always
How often do you feel anxious during the work-week?
(Required)
Never
Sometimes
Frequently
If you don't eat regularly, do you notice your energy or mood diminish?
(Required)
Never
Sometimes
Frequently
How would you rate your "vim, vigor, and drive" throughout the day?
(Required)
Good
Comes and goes
Poor
What vim and vigor
Do you crave salty foods?
(Required)
Yes
No
When stressed do you get irritable?
(Required)
Yes
No
Do you startle readily or do you have jumpy/nervous feelings?
(Required)
Yes
No
Have you taken oral steroids such as: Hydrocortisone, Prednisone, etc. in the last 3 months?
(Required)
Yes
No
How stressed do you feel in life?
(Required)
Not stressed
Mildly stressed
Moderately stressed
Hugely stressed
Do you feel there are too many demands on your time and day?
(Required)
Yes
No
Have you started to or have gained weight specifically in your middle/midriff
(Required)
Yes
No
Do you routinely use prayer, meditation, yoga, deep breathing, or other techniques to help with stress?
(Required)
Yes
No
Do you find yourself stress eating?
(Required)
Yes
No
What best reflects your temperature?
(Required)
Low Body Temperature (cold)
Normal (98.6 F / 37 C)
Elevated (feel hot)
Hair thinning?
(Required)
Yes
No
Loss of Outer 1/3rd of eye brow?
(Required)
Yes
No
Dry Skin or Brittle Hair?
(Required)
Yes
No
Do you have a bowel movement at least once per day?
(Required)
Yes
No
Do you gain weight readily related to how much you eat?
(Required)
Yes
No
Do you have a racing heart at times unrelated to stress or a known heart issue?
(Required)
Yes
No
Do you have trouble gaining weight?
(Required)
Yes
No
Do you feel amped up and then exhausted?
(Required)
Yes
No
Have you been told you have hypoglycemia (low blood sugar)?
(Required)
Yes
No
If you don't eat regularly or miss a meal, do you feel irritable, brain fog, or weak?
(Required)
Yes
No
Have you been diagnosed with high blood sugar, pre-diabetes, or diabetes?
(Required)
Yes
No
How would you describe your weight?
(Required)
Perfect weight
10-19 pounds over ideal weight
20-29 pounds over your ideal weight
30-49 over your ideal weight
>50 pounds over your ideal weight
Do you have energy crashes at times that improve after eating?
(Required)
Yes
No
Do you experience diarrhea during any given week?
(Required)
Yes, four or more times
Yes, more than twice per week
Yes, once per week
No
Do you take a daily probiotic supplement or probiotic rich food?
(Required)
Yes
No
Do you experience excess burping?
(Required)
Yes
No
Do you experience excess lower GI gas?
(Required)
Yes
No
Do you have a history of fungal infections – athlete's foot, nail fungus, yeast infection, jock itch?
(Required)
Yes
No
Do chemical smells such as fragrances or perfumes make you feel poorly?
(Required)
Yes
No
Do moldy, mildew, or damp locations trigger breathing issues, mucous or runny nose?
(Required)
Yes
No
Do you have known food allergies or sensitivities?
(Required)
Yes
No
Do you have gluten sensitivity?
(Required)
Yes
No
Do you have lactose intolerance?
(Required)
Yes
No
Do you experience bloating or distention after eating?
(Required)
Yes
No
Have you been told you are nutrient deficient – like B12 or iron insufficient?
(Required)
Yes
No
Do you have heartburn or acid reflux?
(Required)
Yes
No
Do spicy or rich foods irritate your stomach?
(Required)
Yes
No
Do you have GI discomfort after eating rich, creamy, or fried foods?
(Required)
Yes
No
Do you take antacids or acid blockers for heartburn, gastritis, or GERD?
(Required)
Yes
No
Do you get a runny or stuffy nose frequently?
(Required)
Yes
No
Do you cough after you lay down in bed?
(Required)
Yes
No
Do you get sinus-allergy symptoms?
(Required)
Yes
No
How frequently do you get colds, flus, or sick?
(Required)
Rarely
Once a year
Once every couple of months
Nearly every month
Do you get restless legs at night?
(Required)
Yes
No
Have you had bronchitis or pneumonia in the last 3 years?
(Required)
Yes
No
Do you find it hard to think or remember at times?
(Required)
Yes
No
Does your brain feel sluggish (like brain fog)?
(Required)
Yes
No
Do you find it hard to keep your mind focused on one task?
(Required)
Yes
No
Do you snore?
(Required)
Yes
No
Have you tested positive for apnea or been told to get a sleep apnea test?
(Required)
Yes
No
Do you recall your dreams at least twice per week?
(Required)
No
Sometimes
Always
Do you experience anxiety at least once per week?
(Required)
Yes
No
Do you feel melancholy or depressed?
(Required)
Yes
No
Do you eat for comfort?
(Required)
Yes
No
Has your memory gotten worse over the past year?
(Required)
Yes
No
How many hours of sleep do you get on average?
(Required)
5 or Less
6 to 7
8 to 10
>10
Have you had a gene test that has identified the presence of a positive genetic SNP for folate metabolism or other methylation pathways (MTHF-reductase, COMT, MAO)?
(Required)
Yes
No
Do you have ongoing joint pain?
(Required)
Yes
No
Do you have ongoing muscle pain?
(Required)
Yes
No
Do you get short of breath with minor exertion like walking?
(Required)
Yes
No
Do you get short of breath after climbing a flight of stairs?
(Required)
Yes
No
Do you have asthma?
(Required)
Yes, but it is controlled
Yes, partially controlled
No
Do you get "charley horses"/muscle cramps at night?
(Required)
Yes
No
Do you have ankle or feet swelling by the time you go to bed?
(Required)
Yes
No
Do you currently have elevated blood sugar?
(Required)
Yes
No
Do you currently have elevated total cholesterol (lipids)?
(Required)
Yes, just over 200
Yes, over 250
Yes, over 300
No
Do you have high blood pressure that is not controlled by medication?
(Required)
Yes
No
Do you have increased inflammation in your body?
(Required)
Yes
No
Do your legs or arms feel weak with exertion and tire readily?
(Required)
Yes
No
Do you have cold hands or feet?
(Required)
Yes
No
Do you smoke tobacco or cannabis?
(Required)
Yes, but not daily
Yes, several times a day
Yes, several times a day for years
No
Are you exposed to secondhand smoke?
(Required)
Yes, occasionally
Yes, frequently
Yes, frequently for years
No
Do you have COPD/Emphysema?
(Required)
Yes
No
Do you have body odor beyond normal?
(Required)
Yes, often
Rarely
No
Have you tested high for heavy metals, such as lead, mercury, cadmium, and/or arsenic?
(Required)
Yes
No
Have you tested for chemical burden such as parabens, phthalates, benzene, and/or toulene?
(Required)
Yes
No
Throughout the day, is your urine near-clear (colorless) for at least 4 hours per day?
(Required)
Yes
No
How many ounces of water or tea do you drink per day?
(Required)
Less than 20 ounces
20 to 32 ounces
32 to 48 ounces
48 ounces or greater
How often do you eat organic veggies, fruit, and/or animal products?
(Required)
Only eat organic or free range
Rarely eat organic or free range
Never eat organic or free range
Questions for Men
Have you experienced growth of fat tissue in the breast area?
(Required)
Yes
No
Have you experienced a decreased sex drive/libido?
(Required)
Yes
No
Has your medical provider told you that you have low sex hormones?
(Required)
Yes, but I am not taking them
Yes, I am taking them
No
Have you seen a drop in your muscle mass and overall strength?
(Required)
Yes
No
Have you had an increase in your nighttime urination?
(Required)
Yes, once per night
Yes, two or more times per night
No
Do you have erectile dysfunction?
(Required)
Yes, slightly
Yes, moderately
Yes, must medicate
Yes, medication does not help
No
Questions for Women
PMS Symptons?
(Required)
Yes, only mild
Yes, moderate
Yes, impacts daily responsibilities
No
Menopause or Peri-menopause (still on period, but having menopausal symptoms)?
(Required)
Yes, only mild
Yes, moderate
Yes, impacts daily responsibilities
No
