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Call for a consultation 702.456.6772

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Swirl

Call for a consultation 702.456.6772

Life Align Wellness RSS Feed          info@lifealignwellness.com
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                               Health Survey

                               Health Survey
 

                                        * indicates required field
Name  
Address  
Phone  
Email  
Age  
Company  
Occupation  
I exercise a minimum of 20 minutes per day, 3 days per week
 
I drink a minimum of 8 glasses (64 ounces) of water every day.
 
I eat a minimum of 5 servings of fruits and vegetables every day
 
I take a multi-vitamin most days
 
I sleep, on average, 7 hours or more every night
 
I feel alert and energetic all day most days
 
I participate in at least one enjoyable social activity every week  
I handle my stress well and participate in relaxing activities
 
In the past 30 days, have you experienced:








 
Pain/Tesion/Numbness




 
Digestive Trouble


 
Which bothers you most?:  
How long has this condition existed  
How does it feel at its worst?:  
Does this cause you to be:


 
Does this affect your work:



 
Does this affect your life:

 
If you could get rid of this problem, would you want to?
 
Height  
Weight  
Body Mass Index (Use chart below)  
 
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