Health Risk Assessment

ARE YOU HEALTHY?

Although it is not possible to review ALL of your health parameters with a short quiz, the major items that make up your health are summarized below in thirteen easy-to-answer questions. Take this test at the beginning of the program and repeat the test at the end of the program to confirm your progress.

You must fill out all fields in this form in order to proceed.

1. Do you smoke or use other forms of tobacco? YesNo
2. Do you drink more than 1-2 glasses of alcohol per day on average? YesNo
3. Is your blood sugar above normal? YesNo
4. Is your cholesterol above than normal? YesNo
5. Is your blood pressure above normal? YesNo
6. Do you need to lose more than 10 pounds to be at your ideal weight? YesNo
7. Do you feel your stress level is too high? YesNo
8. Do you feel you suffer from depression or anxiety? YesNo
9. Do you skip your daily 30 minutes of exercise more than you get it in? YesNo
10. Do you eat junk food (cookies, chips, candy, soft drinks) on most days? YesNo
11. Do you feel fatigued most of the time? YesNo
12. Do you feel your diet is lacking in fruits, vegetables and high fiber grains? YesNo
13. Do you have trouble getting seven to nine hours of good quality sleep every night? YesNo