Health Lifestyle Assessment Form Please list your 3 primary goals Please record a food diary for three typical days of your diet. Please include one weekend day. Please record a fitness/workout diary for a typical week. Indicate the day of week and the time of day of each workout. Please indicate if you suffer from any of the following (answers to each question are required) Low Blood Pressure*: NoYes High Blood Pressure*: NoYes Thyroid Condition*: NoYes Irregular Heartbeat*: NoYes Heartburn*: NoYes High Cholesterol*: NoYes Diabetes*: NoYes Nausea*: NoYes Please indicate if you have ever suffered from any of the following Yeast Infections: NoYes Lack of Energy: NoYes Athlete's Foot: NoYes Muscle Fatigue: NoYes Jock Itch: NoYes Nasal Drip: NoYes Skin Rashes: NoYes Sinus Problems: NoYes Eczema: NoYes Neck Pain: NoYes Frequent Headaches: NoYes Back Pain: NoYes Circulation Problems: NoYes Inability to Concentrate: NoYes Joint Cracking: NoYes Joint Pain: NoYes Joint Inflammation: NoYes Brain Fog: NoYes Poor Memory: NoYes Mood Swings: NoYes Depression: NoYes Insomnia: NoYes Irritable Bowel: NoYes Ulcers: NoYes Colitis: NoYes Crohn's: NoYes What level of stress are you experiencing right now? MinimalAverageConsiderableUnbearable Financial: NoYes Career: NoYes Personal: NoYes Marriage: NoYes Health: NoYes Family: NoYes Spiritual: NoYes Unfulfilled Expectations: NoYes Do you awaken feeling rested? NoYes Do you smoke? NoYes Do you drink? NoYes Do you take prescription drugs? NoYes Do you currently take any supplements? NoYes Do you have a personal trainer? NoYes