Complete Balance ~ Health Assessment
Step
1
of
34
2%
Name
*
First
Last
Email
*
Phone
*
This questionnaire is to be used to educate on supplements that may support your body in its natural healing process. This questionnaire and the product statements found in these educational materials have not been evaluated by the Food and Drug Administration. These statements are not intended to diagnose, treat, cure or prevent any disease or symptoms.
I agree
I have a hard time staying asleep once I fall asleep.
*
Never
Sometimes
Regularly
Frequently
Always
I gain/carry weight in my midsection.
*
Never
Sometimes
Regularly
Frequently
Always
I have heart burn.
*
Never
Sometimes
Regularly
Frequently
Always
I have a low libido.
*
Never
Sometimes
Regularly
Frequently
Always
I have less than 2 bowel movements a day.
*
Never
Sometimes
Regularly
Frequently
Always
I have general aches and pains.
*
Never
Sometimes
Regularly
Frequently
Always
I find it difficult to consume enough healthy oils and omegas in my diet.
*
Never
Sometimes
Regularly
Frequently
Always
I feel so stressed or anxious that it hinders my life.
*
Never
Sometimes
Regularly
Frequently
Always
I suffer from bloating or cramping during my menstrual cycle.
*
Never or N/A
Sometimes
Regularly
Frequently
Always
I feel run down at the end of the day.
*
Never
Sometimes
Regularly
Frequently
Always
I suffer from allergies.
*
Never
Sometimes
Regularly
Frequently
Always
I have hormonal issues.
*
Never
Sometimes
Regularly
Frequently
Always
I am agitated easily.
*
Never
Sometimes
Regularly
Frequently
Always
I snack on sugary foods between meals.
*
Never
Sometimes
Regularly
Frequently
Always
I have a difficult time remembering things.
*
Never
Sometimes
Regularly
Frequently
Always
I mentally and/or physically crash in the afternoon.
*
Never
Sometimes
Regularly
Frequently
Always
I have digestive/intestinal issues.
*
Never
Sometimes
Regularly
Frequently
Always
I am often sick due to the flu or cold.
*
Never
Sometimes
Regularly
Frequently
Always
I am sensitive to gluten.
*
Never
Sometimes
Regularly
Frequently
Always
I have diarrhea.
*
Never
Sometimes
Regularly
Frequently
Always
I have dry skin.
*
Never
Sometimes
Regularly
Frequently
Always
I need a stimulant to get going in the morning.
*
Never
Sometimes
Regularly
Frequently
Always
I am concerned about my weight.
*
Never
Sometimes
Regularly
Frequently
Always
I have respiratory issues.
*
Never
Sometimes
Regularly
Frequently
Always
I have a hard time turning off my mind so I can sleep.
*
Never
Sometimes
Regularly
Frequently
Always
My cholesterol is outside the normal range.
*
Never
Sometimes
Regularly
Frequently
Always
My joints are often sore or achy.
*
Never
Sometimes
Regularly
Frequently
Always
I suffer from headaches.
*
Never
Sometimes
Regularly
Frequently
Always
Are you currently taking medications?
*
Yes
No
What struggles are you currently dealing with in your health?
*
What are your biggest concerns around your health and wellness?
*
What is your ultimate long term goal in working with me?
*
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