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PERSONAL WELLNESS EVALUATION

 

Name:

Phone:   State:

Email:

  1. Do you eat more meals with poultry, lean meat, fish and plant (soy) proteins rather than steak, hamburger and other red meat? Yes   No 

  2. Do you eat a variety of colorful fruits and vegetables and do you eat at least seven servings a day? Yes   No 

  3. Do you eat mainly whole grains (100% whole wheat bread, pasta, brown rice)? Yes   No 

  4. Do you eat ocean-caught fish at least three times per week? Yes   No 

  5. Do you avoid fried foods, dressings, sauces, gravies, butter and margarine?  Yes   No 

  6. Do you experience frequent indigestion or irregularity? Yes   No 

  7. Are you overweight? Yes   No 

  8. Are you underweight? Yes   No 

  9. Do you usually have time to prepare a balanced meal at home? Yes   No 

  10. Do you eat at restaurants frequently? Yes   No 

  11. Do you experience water retention and bloating? Yes   No 

  12. Do you have the energy and focus you need to meet daily challenges?  Yes   No 

  13. Do you drink a minimum of 8 glasses of pure water per day? Yes   No 

  14. Are you getting your daily minimum of calcium daily? (Men 1000mg, Women 1200 - 1500) Yes   No 

  15. Are you blood pressure, triglycerides and bad cholesterol in the normal range?   Yes   No 

  16. Men: Are you free from problems associated with your prostate? Yes   No 

  17. Women: Are you free from problems associated with your menstrual cycle or menopause? Yes   No 

  18. Would like a free consultation on any of the above? Yes   No 

Thank your for taking our questionnaire!

(This information is confidential and private and will be treated as such)