Complete Program Registration

Estimated Time: 20 minutes

Number of Sections: 6

This is the complete program registration form. It is meant to serve as a general evaluation tool and improve your program. You can skip questions you don't feel comfortable answering. However, the detail of your submission will have a direct impact the direction of the program.

Section 1 - General Health

Please answer the following question to the best of your ability:

Do you have any heart/cardiovascular issues?

Are you currently pregnant or breast-feeding?

Are you considered overweight?

List any current health issues you currently have (in order of importance):

Health Problem

Duration

Section 2 - Lifestyle

The following questions will evaluate various aspects of your lifestyle, please answer as accurately as possible:

How many times per week do your exercise?

How many hours per day do you sleep?

Do you smoke cigarettes?

Do you believe you have a problem with alcohol consumption?

How hours of your day are spent sitting?

How many hours of your day is spent on relaxation?

Do you get anxious in social situations?

Do you practice any form of regular meditation?

Do you have difficulties getting to sleep?

How active are you in your daily routine (walking, moving around, etc.):

Section 3 - Dietary Habits

Let's focus our attention to your food habits and see if there are any areas for improvement:

Do you believe you have any food allergies or sensitivities?

Do you have any confirmed food allergies?

How many serving of vegetables do you consume daily?

Primary source of protein?

What percentage of your dietary intake comes from packaged foods?

How often do you eat or take out from a fast food restaurant?

Check any vitamin or mineral deficiencies you believe you may have:

Do you take any specific vitamin or mineral supplements for your deficiencies?

Do you take multivitamin supplements?

Are you currently taking any home remedies or herbal supplements?

Are you currently on any special diet?

Are you a vegetarian?

Do you read food labels and inspect the majority of food you consume?

Section 5 - Supplementary

These questions help to uncover other potential factors which may be playing a role:

What age category do you fall into:

Would you consider yourself overweight?

Please check any symptoms that you have experience on an regular basis:

How ready are you to commit to change?

Do you have 15 minutes a week to dedicate to the community?

Is there any additional information you would like to share?

Thank for taking the time to fill your questionaire.
You can expect to recieve an initial response within 2-3 days.

Complete Program Registration

Section 1 - General Health

Section 2 - Lifestyle

Section 3 - Dietary Habits

Section 4 - Skin Specifics

Section 5 - Supplementary

Section 6 - Contact Information