Health Check Evaluation

Full Name

First NameLast Name

Gender

MaleFemale

What are your main health concerns?*

Please rate yourself from 1 - 10 (1=poor / 10=excellent)

for the following questions.

How do you rate your current level of health?*

How do you rate your daily intake our water?*

How do you rate your level of daily exercise?*

Based on 7 days a week, how would you rate your nutritional lifestyle?*

How would you rate your level of stress? (0=Not Managed, 5=Sometimes Managed, or 10= Always managed)*

Overall, do you practice cleansing on a regular basis? (0= No, 5= Sometimes or 10= regularly)*

Overall, how well do you sleep?*

How would you rate your unhealthy habits? (0=Not Managed, 5=Sometimes Managed, or 10= Always managed)*

Do you have any current health concerns?

Additional info you might want to share:

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HEALTH EVALUATION

YOUR GENERAL HEALTH EVALUATION