Get Your Health Score
How many days per week do you exercise?





How many servicgs of fruit & vegetables do you have a day?
How many prescription medications are you on?
How many close friends do you have?
How many times do you attend church per month?
How many alcoholic drinks do you consume per day?
Do you smoke?
How many health problems do you have?
How many pounds overweight are you?
Which of the following do you take regularly?


Hom many health screens have you missed?
Do you take a baby aspirin daily?
Rate your libido from 1-10: 10 being your libido at age 25
How many glasses of water do you drink per day?
How many times do you eat per day?
What is you HgbAIC level? If you don't know, write "don't know"
Have you had a comprehensive hormone assessment?
Do you know your Coronary Calcium Score?
Rate your stress level (1-5) 5 being the most stressed.
Your Name
Your Email
Phone Number
 
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950 E. Alex Bell Rd., OH, 45459

937-310-1304

Please note: Weight loss results vary individual to individual.