Wellness Quiz

HealthyLifeNextExit3Feeling alright?
Not so much?

Want to find out how healthy you really are?

Take our free wellness quiz and we’ll let you know what you can do to feel better now.

By the way, it looks long but it will only take a few minutes to answer. And those few minutes will change your life. We promise!

 

Name:

Email:

Age:

Gender:

MaleFemale

Current Weight:

Height (in inches):

Do you consider yourself:

UnderweightOverweightJust Right

Have you experienced unintentional weight loss or gain of 10lbs or more in the last three months?

YesNo

Check the following statements that apply:

Occassionally or frequently skip mealsSuffer from fatiqueCurrently overweightCrave sweets or carbohydratesSuffer from chronic painSuffer from headaches

Activity Level – Check your current level of work or lifestyle:

Level 1 – Very Light Work: Sitting, standing, driving, reading, computer, etc.Level 2 – Light Work: Light housework, labor, childcare, mechanic, some sitting, etc.Level 3 – Moderate Work: Heavy gardening, housework, labor, no sitting, etc.Level 4 – Heavy Work: Heavy manual labor, construction, digging, etc.

Exercise Level - Check your current level of exercise:

NoneLevel A – Light Exercise: 1-3 times per week, easy pace, stretching, walking, etc.Level B – Moderate Exercise: 2-3 times per week moderate pace, some weights, etc.Level C – Heavy Exercise – 3-4 times per week, vigorous pace, weights, fast running, etc.

Balanced Eating - Check all that apply:

Mixed food diet (animal & vegetable sources)VegetarianVeganSalt RestrictionFat RestrictionStarch / carbohydrate restrictionThe Zone DietTotal calorie restrictionDairy RestrictionWheat RestrictionEgg RestrictionSoy RestrictionCorn RestrictionAll Gluten RestrictionOther Restriction

Servings Per Day:

Fruits - Please enter a value between 0 and 15

Dark green or deep yellow/orange vegetables - Please enter a value greater than or equal to zero.

Grains - Please enter a value between 0 and 15

Beans, peas, legumes - Please enter a value between 0 and 15

Dairy, eggs - Please enter a value between 0 and 15

Meat, poultry, fish - Please enter a value between 0 and 15

Stimulant Use Habits - Check all that apply:

TobaccoAlcohol

Stress Habits:

Choose the level of stress you are experiencing (1 being the lowest)12345

Longevity - Life Enrichment:

I'd like to:
Reduce my risk of degenerative diseaseSlow down my accelerated agingMonitor biomarkers of agingHave less facial wrinklesMaintain a healthier life longerChange from a "treating illness" orientation to a creating a wellness lifestyle

Are you interested in a 7-day gentle cleansing program to improve fat loss and energy levels?

YesNoMaybe