Your Chronic Health Risks at a Glance

1
Personal Information* This field is required.Please fill in all fields
First Name
Last Name
Please Select
Please Select
Male
Female
Gender
Please enter your email
What company or organization (website) directed you to this assessment?
2
Do you take supplements?
Never - Don't Believe in Supplements
Rarely
Sometimes - Not Regularly
Daily without Fail
Daily: 5 - 10 Different Types
Daily: > 10 Different Types
3
Supplements No - Answer
4
Supplements 10+ - Answer
5
How well do you feel normally?Choose any that REGULARLY impact your daily activities.
Well Mostly
Anxious or Depressed
Sleeplessness (Tired)
Chronic Pain
Nagging Stomach Problems
Migraines or Headaches
Lack of Energy
Ear/Nose/Throat/Oral Issues
Frequent Bathroom Visits
Memory Issues
Eye Problem
Other
6
Wellbeing Brain - Answer
7
Wellbeing Gut - Answer
8
Wellbeing Eye - Answer
9
How much sleep do you get - on average?* This field is required.
< 5 Hours
5 - 6 Hours
6 - 7 Hours
7 - 9 Hours
9 - 11 Hours
> 11 Hours
10
Sleep - Answer
11
Do your gums bleed?* This field is required.Pick your TOP answer only.
Never Bleed
Bleed Rarely
Minimally - When Flossing
Moderately - When Flossing
Bleed Easily
Bleed Regularly
Gums Are Painful & Tender
12
Have you been diagnosed with Periodontal disease?* This field is required.
No / Never
Yes - Within 5 Years
Yes - >5 Years - Resolved
Yes - >5 Years - Persistent
13
Oral - Answer
14
What diet style best describes your normal eating habits?* This field is required.
American (Meat, Potato, Veggie)
Fast Food or Pre-packaged Food
Gluten Free
Mediterranean, Paleo or similar
Vegetarian / Vegan with Fish
Protein is a Priority
High Carbs is a Priority
Healthy Fats is a Priority
Low Sugar is a Priority
Low Fat is a Priority
Vegetarian
Vegan
Sometimes Eat Raw/Rare Meat
Other
15
Food - Answer
16
What's Snacking?* This field is required.Indicate how often you snack and what you choose.
Seldom / Never Snack
Snack Between Meals
Snack Before Bed
Snack instead of Breakfast
Chips
Candy Bars
Fruit
Vegetables
Soda / Pop / Energy Drink
Hot Beverage
Sports / Nutrition Bar
Chocolate
Ice Cream
Hard Candy
Other
17
How often do you eat dinner at home?* This field is required.
Never
1 - 2 Times
3 - 4 Times
5 - 6 Times
Always
18
Select all chronic diseases you had or currently have.* This field is required.Select all that apply.
None / Not Applicable
Cataract or Surgery
Glaucoma
Macular Disease
Other Eye Disease
Cancer
Cardiovascular / Heart
Brain - Dementia
Diabetes
Respiratory
Gastrointestinal
Musculoskeletal
Autoimmune (Arthritis)
Mental Health
Not sure
Other
19
What cooking oils do you use at home?* This field is required.Most restaurants use omega-6 oils like soybean, corn, vegetable and canola.
Animal Lard
Avocado oil
Butter
Canola oil
Corn oil
Coconut oil
Cottonseed oil
Crisco
Margarine
Olive oil
Palm oil
Peanut oil
Soybean oil
Sunflower oil
Vegetable oil
Butter substitute
Other
20
Do you get night sweats?* This field is required.
Never / Not Applicable
In the Past but Not Now
When I'm Anxious Only
Rarely - Minor Sweating
Seldom - Minor Sweating
Persistent Night Sweats
Severe - Have to Change Linens
Sweats Often Precede a Fever
Menopause Related Only
Other
21
Sweats - Answer
22
Do you have depression or a history of depression?* This field is required.Answer this if your depression interferes with your daily living. If you haven't had depression for 10 years or more, answer "Never / Not applicable." Pick ALL that apply.
Never - Not Applicable
Almost Never
Seasonal (SAD)
Once in a While
Frequently - Weekly
I'm usually a bit Depressed
I Suffer from Depression
I Have a History of Depression
Diagnosed With Depression
Other
23
How is your memory? Are you forgetful?* This field is required.Also - Indicate if your memory has changed since last year. Select ALL that Apply.
No Memory Issues
Almost None - No Change
Sometimes Forgetful
Forgetful & Worsening
Frequently Forgetful
Frequent & Worsening
Worse After Taking Medications
Other
24
What medications are you currently taking?* This field is required.Please select by treatment target - NOT medication name - TOP 5 ONLY.
Blood Thinner
Asthma Medication / Inhaler
Cholesterol Lowering / Statin
High Blood Pressure
Seizure
Pain
Diabetes
Inflammation
Sinusitis
Hypothyroidism
Acid Reflux
Mood (Depression or Anxiety)
Memory
Eye Problem
None / Not Applicable
Other
25
Medication - Answer
26
I'm HIGHLY motivated to get off medications* This field is required.
Strongly Agree - Very Motivated
Agree - Motivated
Neutral
Disagree - Not Motivated
Srongly Disagree - Meds OK
Not Applicable - Not on Meds
27
Gastrointestinal: Select any disease / problem you CURRENTLY have.* This field is required.Select ALL that apply to you
Frequent Upset or Indigestion
Frequent Constipation
Frequent Diarrhea / Loose Stools
Incontinence
Heartburn / Acid Reflux (GERD)
Frequent Gas
Bloating / Abdominal Pain
Abdominal Pain / Stones
Celiac Disease
Non-Celiac Gut Sensitivity
Bowel Syndrome/Disease
Crohn's Disease
Ulcerative Colitis
Small Intestine Bacteria Overload
Difficulty Swallowing
Polycystic Ovary Syndrome
Bladder Pain or Other Issues
Eroding Teeth
None / Not Applicable
Other
28
Chronic Disease Assessment TOTAL Score:
29
Image FieldPreliminary GRADE A! You life a healthy life. Consider taking the more comprehensive Chronic Disease Assessment or our unique blood-based assessment - the Chronic Disease Temperature - as your blood provides the most accurate measurement of your current health and future health and disease potential.
30
Image FieldPreliminary GRADE B. You have some chronic health risks. Consider taking the more comprehensive Chronic Disease Assessment or our unique blood-based assessment - the Chronic Disease Temperature - as your blood provides the most accurate measurement of your current health and future health and disease potential.
31
Image FieldPreliminary GRADE C. You have a bunch of chronic health risks that could impact the quality of your health if they haven't already. Consider taking the more comprehensive Chronic Disease Assessment or our unique blood-based assessment - the Chronic Disease Temperature - as your blood provides the most accurate measurement of your current health and future health and disease potential.
32
Image FieldPreliminary GRADE D. You have many chronic health risks that could impact the quality of your health significantly if they haven't already. Strongly consider taking the more comprehensive Chronic Disease Assessment or our unique blood-based assessment - the Chronic Disease Temperature - as your blood provides the most accurate measurement of your current health and future health disease potential.
33
Image FieldPreliminary GRADE F! You have an extreme number of chronic health risks - based on this limited assessment - that could impact the quality of your health significantly if they haven't already. Strongly consider taking the more comprehensive Chronic Disease Assessment or our unique blood-based assessment - the Chronic Disease Temperature - as your blood provides the most accurate measurement of your current health and future health and disease potential.
34
GRADE FROM CALCULATION
35
Risks at a Glance - Observations

The following summary is observations and must not be construed as medical advice. This “at a glance” survey does not provide enough detail to provide specific recommendations. These observations are based on our vast experience working with Harvard Medical School providers and functional medicine members of our team.

{supplementsNo}{supplements10}{wellbeingBrain}{wellbeingGut}

{wellbeingEye}

{sleep149}

{oral}

{food}

{sweats}

{medication}

Consider taking the more detailed "Chronic Disease Assessment" that includes a one hour expert consult to gain a better appreciation for your chronic health risks.
36
Submit Page - Click "SUBMIT" on lower right corner.Click SUBMIT on the lower right corner to save and exit.
Should be Empty: