CR500US

PERSONAL HEALTH PROFILE SURVEY

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First Name *
Last Name *
Email *
Phone
Age Female Male
Are you pregnant or nursing Yes No
Use the formula below to calculate your body mass index, then select one of the choices
Please Select One

CLICK HERE FOR BMI CALCULATOR

OVERALL HEALTH

Do any of the following disrupt your life on a daily or weekly basis? (Select all that apply by holding CTRL or Command while clicking) *


STRESS AND HORMONES

How would you describe your menstrual cycle? *
Please Select One
Which statement is closest to the truth regarding your support system?
Please Select One
In the past year, have you had one or more major stressor ?
Please Select One
During the last year, stress in your life has had: *
Please Select One

TOXICITY

Do you smoke ? *
Please Select One
How much alcohole do you drink ? *
Please Select One
Do you eat candy or sugary products? *
Please Select One
How many sodas do you drink per day? *
Please Select One

ENERGY AND SLEEP PATTERNS

How would you describe your sleep pattern *
Please Select One
How would you describe your energy levels ? *
Please Select One