Health Needs Assessment

First Name *

Last Name *

E-mail *

Only if you are 18 years or older, please fully complete the following form to assist us in determining the options that best fit your goals. Our service presents options for informational purposes and is not a substitution for medical treatment; for medical advice, please consult with your physician. If you are a nursing mother, pregnant, or have a pre-existing medical condition, please indicate this under "Additional Comments." Also, please consult with your physician before participating in any diet or exercise program. Once we have reviewed your assessment, we will email you with options most pertinent to achieving your personal goals. Thank you for your patronage!
Personal history:	Heart Disease High Blood Pressure Stroke
Family history:	Heart Disease High Blood Pressure Stroke
Do you smoke?	Yes No
Are you interested in:	Weight Loss Weight Gain Wt. Maintenance
Does your carbohydrate consumption concern you?	Yes No
Does your diet routinely include fruits?	Yes No
Does your diet routinely include vegetables?	Yes No
Does your diet routinely include fish?	Yes No
Are you athletic?	Yes No
Are you interested in power nutrition?	Yes No
Are you interested in free radical fighters with antioxidant ingredients?	Yes No
Would you benefit from "brain foods"?	Yes No
Would you like to have more energy?	Yes No
Age Range:	18 - 25 25 - 35 35 - 45 45 - 55 55 - 65 65+
What are your health and fitness goals?
What are your health and fitness concerns?
Additional Comments: