my health assessment Name * First Name Last Name Email * Phone * (###) ### #### Message Do you feel that your health has gotten worse over the past two years? * Yes No Have you lost or gained more than 10 percent of your body weight over the past five years - even though your were not intentionally dieting? * Yes No Do you have trouble going to sleep or staying asleep? * Yes No Does pain in your joints or muscles limit your physical activity or mobility? * Yes No Do you commonly feel fatigued for no apparent reason? * Yes No Are you frequently depressed or anxious? * Yes No Do you have problems with memory? * Yes No Is there a constant ringing in your ears? * Yes No Do you feel that you are losing your strength? * Yes No Do you take more than two prescriptions medications? * Yes No How about over-the-counter medications? Do you commonly take any of these? * Anti-inflammatories Antacids Analgesics Sleeping remedies Does Not Apply Do you suffer from allergies? * Yes No Do you occasionally have episodes of poor concentration or confusion? * Yes No Do you commonly suffer from shortness of breath or feel winded? * Yes No Have you lost any of your sense of taste or smell over the past few years? * Yes No Do you feel that you have lost significant amount of muscle over the past few years? * Yes No Have you heard from your doctor that you have any of the following? * Elevated blood pressure Elevated blood cholesterol Elevated blood glucose Does Not Apply Has your dentist told you that you have gum or periodontal disease? * Yes No Do you frequently alternate constipation and diarrhea or feel pain or discomfort in your digestive area? * Yes No Have you been told that you have chronic bad breath? * Yes No Are you shorter than you used to be, or have you any evidence of calcium deposits? * Yes No Do you catch every cold and flu that is going around? * Yes No Thank you!