Environmental Risk Evaluation - Vitalleo

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Name*
First Last
Phone*
Date of Birth*
Month
Day
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Vitalleo Nutrition has partnered with your doctor to provide this health research. By continuing, you agree that Vitalleo may share your responses with your doctor. Vitalleo will not share your information with anyone else and will never share, sell, or rent any information about you.
Great! Now we're going to ask a few questions about your general health and diet. Click "next" to continue.

Food and Exercise
Tell us about your food and exercise routines.
Do you exercise 3 or more times a week for 30 minutes?
- Yes
- No
Do you exercise less than 3 times a week for 30 minutes at a pace where you are able to carry a conversation with a little strain (ie huffing or puffing)?
Have you recently attempted to lose weight without success?
- Yes
- No
Do you crave sugar or carbohydrates (ie chocolate, bread)?
- Yes
- No
How often do you crave sugar or carbohydrates?
- Monthly
- Weekly
- Daily
Do you crave stimulants (ie coffee or chocolate)?
- Yes
- No
How often do you crave stimulants?
- Monthly
- Weekly
- Daily
Do you consume caffeine?
- Yes
- No
How frequently do you consume caffeine?
- Monthly
- Weekly
- Daily
Do you drink alcohol?
- Yes
- No
How frequently do you consume alcohol?
- Monthly
- Weekly
- Daily
Do you smoke cigarettes or other tobacco products?
- Yes
- No
This includes any tobacco usage, such as cigarettes, cigars, pipes, and vaping/e-cigarettes.
How frequently do you smoke?
- Monthly
- Weekly
- Daily
Do you eat boxed food more than twice a week?
- Yes
- No
Do you drink any type of soda?
- Yes
- No
How often do you drink soda?
- Monthly
- Weekly
- Daily
Do you drink at least 4 glasses of water per day?
- Yes
- No
Do you eat white flour, white rice or white bread?
- Yes
- No
How often do you consume white flour, white rice or white bread?
- Monthly
- Weekly
- Daily
Do you eat at least 5 servings of vegetables per day?
- Yes
- No
Do you use artificial sweeteners or consume foods that contain them?
- Yes
- No
Artificial sweeteners are products like Aspartame, Splenda, and Nutrisweet.
How frequently do you consume artificial sweeteners?
- Monthly
- Weekly
- Daily
Do you eat fried foods?
- Yes
- No
How frequently do you consume fried foods?
- Monthly
- Weekly
- Daily
Do you feel you get all your needed nutrients from food, and therefore pass on supplements including multivitamins and fish oil?
- Yes
- No
Do you eat sweets or candy?
- Yes
- No
How frequently do you consume sweets or candy?
- Monthly
- Weekly
- Daily
Great!
Let's move on to the next set of indicators.

Energy Levels
How many hours per night do you sleep on average?
- Less than 8 hours
- 8 hours or more
Do you have trouble getting going in the morning, feeling like you need more sleep even if you have gotten 8 hours?
- Yes
- No
Do you feel drowsy during the day?
- Yes
- No
How often do you experience feelings of drowsiness during the day?
- Monthly
- Weekly
- Daily
Do you have episodes of feeling faint or dizzy or a poor sense of balance?
- Yes
- No
How often do you feel faint or dizzy or a poor sense of balance?
- Monthly
- Weekly
- Daily
Do you have anemia (low iron)?
- Yes
- No
Hair, Skin, and Nails
Do you have hair loss, not resulting in baldness (ie noticing more hair on the pillow when you wake, hair loss in shower etc.)?
- Yes
- No
Do you suffer from acne, eczema, or psoriasis?
- Acne
- Eczema
- Psoriasis
Check all that apply
Do you suffer from dry skin or dermatitis?
- Dry Skin
- Dermatitis
Check all that apply
Do your nails have ridges, spots or do they split easily?
- Yes
- No
Do you have difficulty sleeping, have nervousness or hyperactivity?
- Yes
- No
How often do you experience these symptoms?
- Monthly
- Weekly
- Daily
Lifestyle Diseases
Do you feel you are aging quickly?
- Yes
- No
Do you have silver amalgams in your mouth?
- Yes
- No
Do you receive the flu vaccine annually?
- Yes
- No
Have you received the flu vaccine in the past?
- Yes
- No
Do you have a history of exposure to mold?
- Yes
- No
(living in a home with mold, living in a climate with high incidences of mold, working in older buildings, etc.)
Do you have irregular blood sugar, diabetes or pre-diabetes?
- Yes
- No
Do you have heart disease (ie high blood pressure [over 115/75] or high cholesterol), circulatory problems or slow wound healing?
- Yes
- No
Do you have metabolic syndrome: obesity, blood pressure over 115/75, diabetes mellitus and high cholesterol?
- Yes
- No
Have a history of cancer?
- Yes
- No
You're doing great!
Next we're going to look at your body's immunity, digestion, and any pain.

Immunity
Do you suffer from sinus issues, asthma, or allergies?
- Yes
- No
(including rashes, eczema, and hives)
How often do you experience these symptoms?
- Monthly
- Weekly
- Chronic
Do you get frequent colds and flus?
- Yes
- No
Do you have an autoimmune condition?
- Yes
- No
(ie MS, Ulcerative Colitis, Crohn’s Disease, Rheumatoid Arthritis, Meniere’s Disease, and Raynaud’s Phenomenon)
Pain
Do you suffer from joint pain or muscle aches?
- Yes
- No
How often do you suffer from joint pain or muscle aches?
- Monthly
- Weekly
- Chronic
Do you have headaches or migraines?
- Yes
- No
How often do your headaches or migraines occur?
- Monthly
- Weekly
- Chronic
Have you had a history of whiplash or a concussion?
- Yes
- No
Have you received treatment/correction for your whiplash and/or concussion?
- Yes
- No
Do you have chronic pain including fibromyalgia or arthritis?
- Yes
- No
Digestion
Do you have any digestive concerns?
- Yes
- No
(ie bloating, pain, gas, nausea or excessive body odor)
How often do you experience these digestive symptoms?
- Monthly
- Weekly
- Daily
Do you have diarrhea?
- Yes
- No
How often does your diarrhea occur?
- Monthly
- Weekly
- Chronic
Are you constipated?
- Yes
- No
(ie less than one bowel movement a day and or hard or difficult stools)
How frequently does your constipation occur?
- Monthly
- Weekly
- Chronic
Do you have heartburn and/or excessive burping?
- Yes
- No
How often does your heartburn/excessive burping occur?
- Monthly
- Weekly
- Chronic
Keep going!
One last page and you're done!

Lungs and Extremities
Do you have a history of asthma or COPD?
- Yes
- No
How often do you require the use of interventions (ie medication or an inhaler)?
- Monthly
- Weekly
- Daily
Do you have shooting or tingling in your hands, arms, legs or feet?
- Yes
- No
How often do you experience these shooting or tingling symptoms?
- Monthly
- Weekly
- Chronic
Do you have a hot or burning sensation in your feet or tender heels?
- Yes
- No
How often do you experience these hot or burning symptoms?
- Monthly
- Weekly
- Chronic
Do you have muscle cramps, tremors or spasms?
- Yes
- No
How often do you experience these cramps, tremors, or spasms?
- Monthly
- Weekly
- Chronic
I am
- Male
- Female
Questions for Men
Do you feel like you have lost your competitive edge?
- Yes
- No
Do you feel reduced sexual performance or libido?
- Yes
- No
How often do you experience these reduced performance/libido symptoms?
- Monthly
- Weekly
- Chronic
Do you or have you had prostatitis or benign prostatic hypertrophy?
- Yes
- No
Do you have a history of prostate cancer?
- Yes
- No
Questions for Women
Do you take hormonal contraceptives?
- Yes
- No
(ie the birth control pill, patch hormonal creams or Norplant)
Have you previously used hormonal contraceptives?
- Yes
- No
Do you take synthetic estrogen medication?
- Yes
- No
(ie Estratab, Menest, Premarin, Premphase and Prempro)
Have you had difficulties in conceiving or experienced miscarriages?
- Yes
- No
Do you have Pre-menstrual Syndrome (PMS)?
- Yes
- No
(ie breast tenderness or water retention, mood changes, discomfort or pain)
Do you or have you had fibrocystic breasts, uterine fibroids, or cervical dysplasia?
- Yes
- No
Are you peri-menopausal or menopausal?
- Yes
- No
(ie changeable periods, hot flashes, heavier periods, changeable moods)
That's it!
Click the submit button to send your results to your doctor.
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Final Score

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