Healthy Living Questionnaire Name Age 101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100 Gender Male Female Weight 50 lbs51 lbs52 lbs53 lbs54 lbs55 lbs56 lbs57 lbs58 lbs59 lbs60 lbs61 lbs62 lbs63 lbs64 lbs65 lbs66 lbs67 lbs68 lbs69 lbs70 lbs71 lbs72 lbs73 lbs74 lbs75 lbs76 lbs77 lbs78 lbs79 lbs80 lbs81 lbs82 lbs83 lbs84 lbs85 lbs86 lbs87 lbs88 lbs89 lbs90 lbs91 lbs92 lbs93 lbs94 lbs95 lbs96 lbs97 lbs98 lbs99 lbs100 lbs101 lbs102 lbs103 lbs104 lbs105 lbs106 lbs107 lbs108 lbs109 lbs110 lbs111 lbs112 lbs113 lbs114 lbs115 lbs116 lbs117 lbs118 lbs119 lbs120 lbs121 lbs122 lbs123 lbs124 lbs125 lbs126 lbs127 lbs128 lbs129 lbs130 lbs131 lbs132 lbs133 lbs134 lbs135 lbs136 lbs137 lbs138 lbs139 lbs140 lbs141 lbs142 lbs143 lbs144 lbs145 lbs146 lbs147 lbs148 lbs149 lbs150 lbs151 lbs152 lbs153 lbs154 lbs155 lbs156 lbs157 lbs158 lbs159 lbs160 lbs161 lbs162 lbs163 lbs164 lbs165 lbs166 lbs167 lbs168 lbs169 lbs170 lbs171 lbs172 lbs173 lbs174 lbs175 lbs176 lbs177 lbs178 lbs179 lbs180 lbs181 lbs182 lbs183 lbs184 lbs185 lbs186 lbs187 lbs188 lbs189 lbs190 lbs191 lbs192 lbs193 lbs194 lbs195 lbs196 lbs197 lbs198 lbs199 lbs200 lbs201 lbs202 lbs203 lbs204 lbs205 lbs206 lbs207 lbs208 lbs209 lbs210 lbs211 lbs212 lbs213 lbs214 lbs215 lbs216 lbs217 lbs218 lbs219 lbs220 lbs221 lbs222 lbs223 lbs224 lbs225 lbs226 lbs227 lbs228 lbs229 lbs230 lbs231 lbs232 lbs233 lbs234 lbs235 lbs236 lbs237 lbs238 lbs239 lbs240 lbs241 lbs242 lbs243 lbs244 lbs245 lbs246 lbs247 lbs248 lbs249 lbs250 lbs251 lbs252 lbs253 lbs254 lbs255 lbs256 lbs257 lbs258 lbs259 lbs260 lbs261 lbs262 lbs263 lbs264 lbs265 lbs266 lbs267 lbs268 lbs269 lbs270 lbs271 lbs272 lbs273 lbs274 lbs275 lbs276 lbs277 lbs278 lbs279 lbs280 lbs281 lbs282 lbs283 lbs284 lbs285 lbs286 lbs287 lbs288 lbs289 lbs290 lbs291 lbs292 lbs293 lbs294 lbs295 lbs296 lbs297 lbs298 lbs299 lbs300 lbs301 lbs302 lbs303 lbs304 lbs305 lbs306 lbs307 lbs308 lbs309 lbs310 lbs311 lbs312 lbs313 lbs314 lbs315 lbs316 lbs317 lbs318 lbs319 lbs320 lbs321 lbs322 lbs323 lbs324 lbs325 lbs326 lbs327 lbs328 lbs329 lbs330 lbs331 lbs332 lbs333 lbs334 lbs335 lbs336 lbs337 lbs338 lbs339 lbs340 lbs341 lbs342 lbs343 lbs344 lbs345 lbs346 lbs347 lbs348 lbs349 lbs350 lbs351 lbs352 lbs353 lbs354 lbs355 lbs356 lbs357 lbs358 lbs359 lbs360 lbs361 lbs362 lbs363 lbs364 lbs365 lbs366 lbs367 lbs368 lbs369 lbs370 lbs371 lbs372 lbs373 lbs374 lbs375 lbs376 lbs377 lbs378 lbs379 lbs380 lbs381 lbs382 lbs383 lbs384 lbs385 lbs386 lbs387 lbs388 lbs389 lbs390 lbs391 lbs392 lbs393 lbs394 lbs395 lbs396 lbs397 lbs398 lbs399 lbs400 lbs401 lbs402 lbs403 lbs404 lbs405 lbs406 lbs407 lbs408 lbs409 lbs410 lbs411 lbs412 lbs413 lbs414 lbs415 lbs416 lbs417 lbs418 lbs419 lbs420 lbs421 lbs422 lbs423 lbs424 lbs425 lbs426 lbs427 lbs428 lbs429 lbs430 lbs431 lbs432 lbs433 lbs434 lbs435 lbs436 lbs437 lbs438 lbs439 lbs440 lbs441 lbs442 lbs443 lbs444 lbs445 lbs446 lbs447 lbs448 lbs449 lbs450 lbs451 lbs452 lbs453 lbs454 lbs455 lbs456 lbs457 lbs458 lbs459 lbs460 lbs461 lbs462 lbs463 lbs464 lbs465 lbs466 lbs467 lbs468 lbs469 lbs470 lbs471 lbs472 lbs473 lbs474 lbs475 lbs476 lbs477 lbs478 lbs479 lbs480 lbs481 lbs482 lbs483 lbs484 lbs485 lbs486 lbs487 lbs488 lbs489 lbs490 lbs491 lbs492 lbs493 lbs494 lbs495 lbs496 lbs497 lbs498 lbs499 lbs500 lbs501 lbs502 lbs503 lbs504 lbs505 lbs506 lbs507 lbs508 lbs509 lbs510 lbs511 lbs512 lbs513 lbs514 lbs515 lbs516 lbs517 lbs518 lbs519 lbs520 lbs521 lbs522 lbs523 lbs524 lbs525 lbs526 lbs527 lbs528 lbs529 lbs530 lbs531 lbs532 lbs533 lbs534 lbs535 lbs536 lbs537 lbs538 lbs539 lbs540 lbs541 lbs542 lbs543 lbs544 lbs545 lbs546 lbs547 lbs548 lbs549 lbs550 lbs551 lbs552 lbs553 lbs554 lbs555 lbs556 lbs557 lbs558 lbs559 lbs560 lbs561 lbs562 lbs563 lbs564 lbs565 lbs566 lbs567 lbs568 lbs569 lbs570 lbs571 lbs572 lbs573 lbs574 lbs575 lbs576 lbs577 lbs578 lbs579 lbs580 lbs581 lbs582 lbs583 lbs584 lbs585 lbs586 lbs587 lbs588 lbs589 lbs590 lbs591 lbs592 lbs593 lbs594 lbs595 lbs596 lbs597 lbs598 lbs599 lbs600 lbs Do you consider yourself Under Weight Over Weight Just Right Unintentional weight loss or gain of 10 pounds or more in the last 3 months? No Yes Recent changes in your ability to See Hear Taste Smell Feel hot/cold sensations General conditions Occasionally or frequently skip meals Suffer from fatigue Currently overweight Crave sweets or carbohydrates Crave stimulants, such as caffeine or soft drinks Suffer from chronic pain Suffer from headaches Activity level / Lifestyle Level 1 - Very light work / inactive Level 2 - Light work / somewhat active Level 3 - Moderate work / active Level 4 - Heavy work / very active Exercise level None Level A - Light exercise Level B - Moderate exercise Level C - Heavy exercise Balance eating Mixed food diet (animal and vegetable sources) Vegetarian Vegan Salt restriction Fat restriction Starch / carbohydrate restriction The zone diet Total calorie restriction Dairy restriction Wheat restriction Egg restriction Soy restriction Corn restriction All gluten restirction Other Servings per day Fruits (citrus, melons, etc.) 01234567891011121314 Dark green or deep yellow / orange vegetables 01234567891011121314 Grains (unprocessed) 01234567891011121314 Beans, peas, legumes 01234567891011121314 Dairy, eggs 01234567891011121314 Meat, poultry, fish 01234567891011121314 Eating frequency Skip breakfast or other meals Three meals per day Two meals per day One meal per day Graze-small frequent meals Generally eat on the run Exercise frequency 5-7 days per week 3-4 days per week 1-2 days per week Exercise duration 5-7 days per week 3-4 days per week 1-2 days per week Exercise circumstances Use personal trainer Member of fitness club Own exercise equipment Exercises (days per week) Walk 0123456 Run, jog, jump rope, aerobic 0123456 Weight lift 0123456 Stretch 0123456 Yoga 0123456 Other 0123456  Stimulant Use Habits Cigarettes (per day) 01234567891011121314151617181920212223242526272829 Cigars (per day) 01234567891011121314151617181920212223242526272829 Pipe (per day) 01234567891011121314151617181920212223242526272829 Wine (glasses/day) 01234567891011121314151617181920212223242526272829 Liquor (ounces/day) 01234567891011121314151617181920212223242526272829 Beer (glasses/day) 01234567891011121314151617181920212223242526272829 Coffee (6oz cups/day) 01234567891011121314151617181920212223242526272829 Tea (6oz cups/day) 01234567891011121314151617181920212223242526272829 Soda w/ caffeine (cans/day) 01234567891011121314151617181920212223242526272829 Soda w/o caffeine (cans/day) 01234567891011121314151617181920212223242526272829 Other caffeine sources  Water (glasses/day) 01234567891011121314151617181920212223242526272829 Stress level (1 is the lowest/least) 12345678910 Stress causes Is your job associated with potentially harmful chemicals, pesticides, radioactivity, or solvents? No Yes Do you suffer from insomnia / sleep disorders? No Yes Do you often abruptly awake from sleep? No Yes Do you suffer from depression/mood swings? No Yes Supplement use habbits Multivitamin / mineral Vitamin C Vitamin E EPA / DHA GLA Primerose Evening Primerose Calcium Magnesium Zinc Minerals Friendly flora (Acidophilus) Digestive enzymes Amino acids CoQ10 Antioxidants (lutein,resveritol,etc.) Herbs - tea Herbs - extracts Chinese herbs Ayurvedic herbs Homeopathy Bach Flowers Super foods (bee pollen, phytonutrient blends) Liquid meals (Ensure) Other Energy - Vitality (I'd like to...) Have more energy Have longer endurance Have more motivation Sleep better Be less tired after lunch Feel more vital Regain vitality and vigor of my younger years Get less colds and flu's Get rid of allergies Not use so many over the counter drugs Laxatives Be free of pain Longevity - Life enrichment (I'd like to...) Reduce my risk of degenerative disease Slow down accelerated aging Monitor biomarkers of aging Have less facial wrinkles Maintain a healthier life longer Change from a treating illness orientation to creating a wellness lifestyle Body Composition - Fat / Muscle (I'd like to...) Be stronger Be thinner Be more muscular Burn more body fat Be more flexible Lose weight Stress Reduction - Mental / Emotional (I'd like to...) Be happier Be less depressed Be less moody Be less indecisive Be more focused Think more clearly Improve my memory Learn how to reduce stress Learn how to meditate Comments Member Log In Remember me Log-In Reset My Password Register a New Account Shopping Cart 0 items $0.00 View / Checkout Free shipping on orders $100.00 or over! Client List

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