Health Survey

Name (required)

Phone (required)

Email (required)

Age (required)

Occupation?

Best time to contact you:

Do you consider yourself healthy?
YesNo

Are you a smoker now?
YesNo

If no, have you ever smoked?
YesNo

If yes, when did you quit smoking?

Do you exercise regularly?
YesNo

If yes, please state the activities and frequency of exercise:

Do you drink coffee?
YesNo

If yes, please state the approximate amount per day:

Are you taking nutritional supplements?
YesNo

If yes, please mention what brand:

Please indicate if there is any history of the following diseases in your family:?
DiabetesHypertensionHeart AttackStrokeCancerArthritis

Do you feel stressed mostly all of the time?
YesNo

Do you feel that stress is caused or related to the situation at your job, relationship or financial challenges or something else?
YesNo

Do have a good 8-9 hours of sleep every night?
YesNo

Would you like to change something in your life?
YesNo

If yes, please mention what would that be:

If Yes, do you believe this is possible?
YesNo