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Body Evaluation

Body Evaluation

First name

Last name

Email

Cell Phone

Age

Male
Female

Current weight

Goal weight

Skype Address (for people out of the US)

Please rate the below questions

Energy Level

1 2 3 4 5 6 7 8 9 10

Low Energy

High Energy

Sleep Quality

1 2 3 4 5 6 7 8 9 10

Poor

Excellent

Sleep Hours

1 2 3 4 5 6 7 8 9 10

Poor

Excellent

Stress Tolerance

1 2 3 4 5 6 7 8 9 10

Low Tolerance

High Tolerance

Vaginal Dryness
Low Tolerance to Stress
Loss of Vitality ('get up and go')
Dizzy When Standing Up Too Fast
Out of Breath when Climbing Stairs
Loose Skin (loss of collagen)
Hair Loss

Not Satisfied After Meals
Poor Night Vision
Dry Eyes
Gallstones
Asthma
Salt Cravings
Painful Intercourse

Frequent Urination (women)
Osteoporosis or Osteopenia
Sleep Apnea
Need for Afternoon Nap
Acid Reflux (heartburn)
Low Libido (woman)
Low Testosterone (men)

Chocolate Cravings
Allergies
Heavy Menstrual Cycle
Sugar Cravings
High Blood Pressure
Edema (fluid retention)
Hearing Loss

Rosacea (red cheeks)
Trigger finger (Dupuytren's contracture)
Prostate Enlargement
Urinary Frequency (men)
Leaky Gut
Ulcer
High Pulse Rate

Wakes Up Exhausted
Spurs (heel, joints, etc.)
Ringing in the Ear (tinnitus)
Arrhythmia, palpitations (irregular heartbeats)
Dry Cough
Bleeding gums
Sinus Congestion

Indigestion
Chronic Pain
Psoriasis (dry flaky skin patches)
Itching
Lipoma (fatty cyst on body)
Gets Sick Easily
Wakes up in the Middle of the Night

Loss of Memory
Infertility
Excessive Brain Chatter (at night)
PCOD (Polycystic Ovarian Disorder)
Stubborn Weight
Hashimoto's Disease (autoimmune type hypothyroid)
Hypothyroidism

Anemia
Low Vitamin D Levels
Acne
Sleeping Problem
Small Pimples (not red) on Skin
Dry Scaly Skin
Takes Too Long to Recover from Exercise

Legs get heavy after climbing or doing inclined exercise
Nightmares
Hyperthyroid or Graves (autoimmune type thyroid)
Hot Flashes
Blood sugar imbalances (hypoglycemia or diabetes)
Fatigue
Constipation

Bloating, belching or burping
Arthritis, bursitis, tendinitis and inflammation
Fibromyalgia
Muscle Cramps (esp. at night)
Air hunger, labored breathing or sighing
Muscle Twitches (tetany)
Depression

Excessive worrying and anxiety
Attention Deficit Disorder (ADD)
Varicose Veins or Spider Veins
Clogged or Calcified Arteries
Cataracts
Headaches
Mid-back Pain or Tightness

Neck Pain
Right Shoulder Pain
Sensation of Sand or Irritation in Eyes
Tingling, Burning, or Numbness in Fingers or Toes
High Cholesterol
PMS
Cysts (fibrocystic breasts and ovarian cysts)

Brain Fog
Cold Hands or Feet
Male Pattern Baldness
Loss of Hair in Patches (alopecia)
Hair Thinning
Brittle Nails or Ridged Nails
Loss of Outer Eyebrows

Cracks in Corners of the Mouth (cheilosis)
Calf Tenderness

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Disclaimer: The dietary and other substances, and/or materials, equipment or devices discussed on this site may not have undergone evaluation and/or testing
by the United States Food and Drug Administration or like agency of any other country. Risks that might be determined by such testing are unknown.
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These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure or prevent any disease. Information on this site is provided for informational purposes only, it is not meant to substitute medical advice provided by your physician or any other medical professional. You should not use the information contained on this site for diagnosing or treating a health problem, disease, or prescribing any medication. Please read product label before use. Best results are only achieved when combined with diet and exercise program. Results not typical for any or all claims.