Contact Information Notice:

Your information is strictly confidential and only used to customize your report. We adhere to strict PHI and HIPAA guidelines.

Name *

First Name

Last Name

Gender *

Female

Male

Do you smoke cigarettes or cannabis at least once a week? *

Yes

No

How many alcoholic beverages do you consume per week? *

<3

3-7

>7

Age *

<40

40-60

>61

How many hours of sleep do you typically get per night? *

<6

6-8

>8

How would you rate your daily energy levels? *

low

moderate

high

How would you rate your ability to concentrate on a given task for more than 20 minutes? *

low

moderate

high

How would you rate your average daily stress level? *

low

moderate

high

Which of these symptoms do you experience on a weekly basis? *

Brain fog

Mood swings

Poor sexual performance

Muscle joint pains

Fatigue

Bloating

Stomach cramps

Rashes

Diarrhea

Canker sores

Allergies

Weight issues

Frequent colds

Afternoon energy slumps

Headaches

Do you, or anyone in your immediate family have any health history with any of the following: *

Cancer

Heart Disease (Hypertension, High Cholesterol, Cardiovascular Disease)

Alzheimer's

Diabetes

Stroke

Depression

Kidney Disease

Arthritis/Sports Injuries

Thyroid

None

Build Type *

Lean

Moderate

Muscular

What are your health and wellness goals? *

Weight loss

Muscle building

Increased energy

Improved flexibility/mobility

Stress reduction

Enhanced endurance

General health and wellness

Dietary improvements

*

I acknowledge that by completing this Health Risk Assessment, I am voluntarily disclosing personal health information. I give my consent for this information to be used for the purposes of assessing my health risks and providing personalized health recommendations. I understand that my information will be handled with confidentiality and in accordance with applicable privacy laws and regulations.