HRP Chronic Disease Assessment (CDA)™️

1
1.1 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
Home Zip Code
Phone Number
Who directed you to Health Revival Partners?
2
1.2 What is your date of birth? mm/dd/yyyy* This field is required.
3
1.3 What is your current age?* This field is required.
< 10
10 - 19
20 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
≥ 80
4
1.4 What jobs have you had?* This field is required.Only select those you had for 1 YEAR or more (scroll to see ALL)
Sanitation or Grounds Work
Chemical, Painting, Agriculture
Executive, Manager, Admin.
Metal Worker, Mining, Automotive
Construction, Physical Work
Medical
Truck Driver
Retail, Restaurant
Sedentary Work
Student, Homemaker
Other (indoor work)
Other (outdoor work)
Other
5
1.5 Do you take supplements?* This field is required.
Never - Don't Believe in Supplements
Rarely
Sometimes - Not Regularly
Daily without Fail
Daily: 5 - 10 Different Types
Daily: > 10 Different Types
6
1.6 What States have you called "home?"* This field is required.Only enter those you have lived in for MORE THAN 1 YEARS. If non-U.S. Indicate Canada, Mexico, or enter your home country.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Federated States of Micronesia
Guam
Puerto Rico
Virgin Islands
A Military "State":
Canada
Mexico
Other
7
1.7 Where have you traveled overseas?* This field is required.Only select countries or regions where you have stayed 1 MONTH or more.
Not Applicable
Africa
Asia
Australia/New Zealand
Canada
Caribbean
Central America/Mexico
South America
Europe
Other
8
1.8 What is your ancestral heritage?* This field is required.Please select all that apply.
African
West European
Native American (Indian)
Mediterranean
Asian
Ashkenazi
Middle Eastern
East European
Australian / New Zealander
Hispanic
African American
Other
9
1.9 What level of schooling have you completed?* This field is required.Pick only ONE
None
Junior High
High School
Some College
Technical College
Associates Degree
College Degree
Graduate Degree
10
1.10 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
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1.11 I'm willing to work with a health coach to improve my health.* This field is required.
Strongly Agree - Very Motivated
Agree - Motivated
Neutral
Disagree - Not Motivated
Strongly Disagree - OK as is
12
1.12 Do you take a vitamin D supplement?* This field is required.
No - Never or Very Rarely
Sometimes - Not Regularly
Frequently (at least Weekly)
Daily
Daily - 5000IU or More
13
1.13 Please rate your overall health status* This field is required.Don't just consider today. Instead rate your health based on the past year.
Excellent
Good
Fair
Poor
Not sure
14
1.14 How motivated are you to become more healthy?* This field is required.
Highly motivated
Motivated
Neutral
Not motivated
Highly unmotivated
15
1.15 Describe your support system. Do you have people in your life who help you with problems or help you improve?* This field is required.Consider both friends and family when answering this.
Very strong support
Strong support
Neutral
Not much support
Little or no support
16
CDA Score 1 - Personal Information
17
2.1 How well do you feel normally?* This field is required.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
Struggling with Weight
Other
18
2.2 How frequently do you have HIGH stress or anxiety?* This field is required.
Never
Rarely (1-2 times/year)
Occasionally (monthly)
Frequently (weekly)
Daily
Continually
19
2.3 Select what is contributing to your stress or anxiety* This field is required.Chose all applicable answers from dropdown.
Childhood Trauma (Death in Family, Abuse)
Finances
Work, Job or School
Discrimination or Bullying
Post Traumatic Stress (PTSD)
Child Issue (Health, Behavior, School)
Personal Relationships
Health
Divorce
Pregnancy
Major Life Change
Lack of Time (Frustration)
Care of Elderly Family Member
Other
None / Not Applicable
20
2.4 What is your level of exercise weekly?* This field is required.Pick only one - or enter in "Other"
None / Never Exercise
Once / Week
2-3 Times / Week
4-6 Times / Week
Daily
Fanatical
Active but do NOT Exercise
Other
21
2.5 What activities do you do at least weekly?* This field is required.Pick ALL that apply.
Gym (Weights, Crossfit, etc)
Walk or Hike
Bike or other Cardio
Garden
Yoga, Meditation or Related
Hunt, Fish, Outdoor Activity
Run
In Home Activity
Other
22
2.6 Do you have pets or animals?* This field is required.
No
Yes Cats Only
Yes - Including Cats
Yes - No Cats
Yes - Farm Animals Only
Other
23
2.6a Where are your pets allowed?* This field is required.
Indoors Only
Outdoors Only
In or Out - NOT on furniture
In or Out - ALLOWED on furniture
Other
24
2.7 How much sun exposure do you get?* This field is required.
None / Almost None
Limited - Don't Tan
Modest - Get Some Sun
Sensible - Seek Sun Regularly
Sun Lover - Enjoy a Good Tan
Have "Burned" in the Past
Use Tanning Booths Regularly
Other
25
2.8 What allergens affect you?* This field is required.Please select all that apply.
Mold
Tree Bark
Animal Dander
Latex
Cleaning Agents
Grass
Dust Mites
Cockroaches
Alcohol
Pollen
Insect Stings
Chemicals
One or More Medicines
None
Not Sure
26
2.9 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
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2.10 What disturbs your sleep?* This field is required.Choose all that apply AT LEAST once each week or answer "nothing."
Sleep Apnea
Insomnia
Restless Leg Syndrome
Interruptions (Environment)
Movement Disorder
Need for Bathroom
Computer / TV / Phone
Alarm Clock
Nothing / Not Applicable
Other
28
2.11 What is bedtime usually - during the week* This field is required.
Before 8pm
8 - 9pm
9 - 10pm
10 - 11pm
11-12pm
Midnight or after
I work 2nd Shift
I Work 3rd Shift
Other
29
2.12 Do you take a nap during the day?* This field is required.
Never
Rarely
Sometimes
Frequently
Daily
Weekends
Other
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2.13 How long does it take you to fall asleep?* This field is required.Pick from a value or add your own in "Add Note Here.."
< 5 Minutes
5 - 20 Minutes
> 20 Minutes
Other
31
2.14 Select the sleep aids you use.* This field is required.
None
Eye Cover
Ear Plugs
White Noise
Sleeping Pills
Antihistamines
Sedatives
Melatonin
Valerian
Mood Drug (depression, anxiety type)
Alcoholic Drink
Complete Darkness
Nyquil or other OTC Drug
Melatonin
Other (not listed)
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2.15 Select any supplement you take a least once each week.* This field is required.
Alpha Lipoic Acid
Amino acid(s) like beta Alanine
Antioxidant (Vitamin E, NAC, other - NOT Vitamin C)
B Vitamin(s)
Blue-Green algae, chlorophyll, chlorella, or similar
Caffeine, ginseng or other stimulant
Calcium
Choline
Creatine, hormone (DHEA) or other muscle builder
Coconut oil
Cod liver oil
Coenzyme Q10 (CoQ10), Ubiquinone, Ubiquinol
Folic Acid or Folate
Garlic
Iron
L-Arginine, Citrulline, or other nitric oxide booster
Magnesium
Methylating Supplement (Betaine, SAM-e, Folate, B-12, TMG, MSM)
Mineral supplement (without vitamins)
Multivitamin and Mineral
Niacin
Omega-3 Supplement, Fish oil, Krill Oil
Probiotic
Protein powder or bar
Potassium
Psyillium or other form of soluble fiber
Turmeric (Curcumin) or other spices as a supplement
Vitamin C
Vitamin D
Vitamin K2
Other supplement(s) not listed
None - I don't take supplements
33
2.16 Do you wear a seatbelt?* This field is required.
Yes - Always
Yes - As a Passenger
Most of the Time
Sometimes
No - Seldom if ever
Not Applicable
34
2.17 Do you or have you always practiced safe sex?* This field is required.
Yes - Always
No - Never or Seldom
Sometimes
Not Applicable
Other
35
2.18 Do you smoke - cigars, cigarettes, chew or vape?* This field is required.If you have in the last 10 years click on "YES"
YESNO
36
2.18a Please answer these smoking related questions.* This field is required.Select ALL that apply.
Cigarettes
Cigars
Chew
Vaping
Casual
Moderate
Heavy
Quit
Other
37
2.19 Do you drink alcohol - beer, wine or hard liquor?* This field is required.If you drink less than 1 time each week, answer "NO"
YESNO
38
2.19a Please answer these alcohol related questions.* This field is required.Select ALL that apply.
Beer
Wine
Hard Liquor
1-4 Servings / Week
5 - 10 Servings / Week
2 - 4 Servings / Day
> 4 Servings / Day
Other
39
2.20 Indicate recreational substances you have used.* This field is required.
Never Used / Not Applicable
Marijuana
Heroin
Heroin Sharing Needles
Ecstasy
Opium
Barbiturates/Benxodiazepines
Amphetamines
Cocaine
Solvents
LSD
Psychedelic Mushrooms
Other
40
2.21 Are you interested in being more physically active?* This field is required.Please choose ALL that apply.
Very interested and motivated
Interested and motivated
Not interested
Not motivated
I get enough exercise
I don't have the time
Very interested - not motivated
I am unable to exercise more
I cannot exercise
Something is holding me back
Other
41
CDA Score 2 - Lifestyle Information
42
3.1 How often do you BRUSH your teeth?* This field is required.
Never
Seldom
Occasionally
Daily
Twice Daily
After Every Meal
43
3.2 How often do you FLOSS your teeth?* This field is required.
Never
Seldom
Occasionally
Daily
Twice Daily
After Every Meal
44
3.3 Do your gums bleed?* This field is required.Select ALL that apply.
Never
Minimally - When Flossing
Moderately - When Flossing
Bleed Easily
Bleed Regularly
Gums Are Painful & Tender
Other
45
3.4 What toothpaste & oral products do you use?* This field is required.
Conventional Toothpaste
Baking Soda
Oil Pulling
Salt
Sensodyne
Toms of Maine
Avoid Fluoride Products
Do Not Brush
Whiteners
Mouth Wash
Dentist Prescribed
46
3.5 How often do you see a dentist?* This field is required.
Never / Almost Never
< 1 Time / Year
1 Time / Year
2 Times / Year or More
47
3.6 Is your home water fluoridated?* This field is required.
Yes
No
Not Sure
48
3.7 Do you have dental implants, root canals, or dentures?* This field is required.
YESNO
49
3.7a Implants, root canals or dentures - Select all that apply* This field is required.
Implants are >10 years old
Implants installed
Root canals >10 years old
Root canals installed
Dentures > 10 years old
Dentures installed last 10 years
Other
50
3.8 Have you been diagnosed with Periodontal disease?* This field is required.
No / Never
Yes - Within 5 Years
Yes - But Resolved
Yes - >5 Years - Persistent
51
3.9 How many cavities (fillings) do you have?* This field is required.Pick the SINGLE best answer
None / Never Had
1 to 5
6 to 10
> 10
None Now - Removed
No Mercury
Other
52
3.10 How many teeth have you lost or had extracted?* This field is required.Do NOT include wisdom teeth, baby teeth or teeth lost in an accident.
None
1 to 5
6 to 10
> 10
Loss due to oral hygiene
Other
53
CDA Score 3 - Oral Health
54
4.1 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
55
4.2 What's for Breakfast?* This field is required.Choose no more than 6 entries.
Doughnut (Donut)
Dairy
Eggs
Fruit
Fruit juice or sweet beverage
Granola
Healthy fats
Hot beverage
Often / always skip breakfast
Fast often (intentionally)
Low fat option
Meat (bacon, sausage, ham)
Oatmeal
Bread / Pancake / Cereal
Water / unsweetened beverage
Vegetables
Other
56
4.3 What's for Lunch?* This field is required.Indicate what you do most regularly. Choose up to 6 entries
Often / Always Skip Lunch
Cafeteria (American Style)
Fast Food
Prepared Fresh
Pre-packaged by Me
Pre-packaged - Store Bought
Restaurant (Nice with Waiter)
Chain Restaurant
Seek Healthy Choices
Skip Lunch for Fasting
Other
57
4.4 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
Healthy Nuts
Other
58
4.5 How often do you eat dinner at home?* This field is required.
Never
1 - 2 Times
3 - 4 Times
5 - 6 Times
Always
59
4.6 How often is food prepared FRESH at home?* This field is required.Do not include pre-packaged, frozen, microwaveable, canned or take-out meals.
Never
1 - 2 Times
3 - 4 Times
5 - 6 Times
Always
60
4.7 How many times each week do you obtain food or a snack from a gas station or convenience store?* This field is required.
Never / Seldom
1 - 2 Times
3 - 4 Times
5 - 6 Times
Daily
Daily Multiple Times
61
4.8 List your TOP 3 restaurant choices* This field is required.If your restaurant isn't listed, pick one that serves similar foods.
IHOP, waffle house
Burger or hot dog establishment
Chinese
Chicken fast food
Denny's, Bob Evans
Dessert or Candy Shop
Doughnut shop
Fast Food
Japanese, Thai, Korean, Indian
Pizza, Subs, Deli
Chipotle, Panera, Applebees
Chain Restaurant
Restaurant with cloth napkins
Mexican, Wings
Dine out infrequently
Other
62
4.9 How frequently do you consume foods with healthy fats?* This field is required.This includes foods like Nuts, Butter, grass-fed Meats, Avocado and Coconut Oil, Olive Oil, Chia, Hemp, or Flax Seeds. It also includes other saturated, mono-unsaturated or omega-3 containing fats not listed here. This question does not pertain to cooking oils.
Never
Rarely
Sometimes
Frequently
All the Time
63
4.10 Describe your relationship with sugar & sweets* This field is required.
Relieved when eating them
Regularly purchase sweets
Guilt after "enjoying" them
Sweets are my snack
Have a sweets stash
Fail at resisting sweets
Withdrawal happens
Eat too many sweets
Pick dessert over food
Addicted to sugar & sweets
Seldom eat sweets
I read labels and avoid sweets
64
4.11 What foods cause an allergic reaction?* This field is required.
Wheat
Eggs
Peanuts
Gluten
Other Nuts
Soy
Shellfish
Dairy
Tree Nuts
Grains
Not Sure / Not Tested
None
Other
65
4.12 What foods do you avoid?* This field is required.Because of taste, cost, dietary restriction, or personal reasons. Pick no more than 6.
Fast Food
Fried Food
Fish
Organ Meat
Grass-fed meats
Organically grown
Vegetables
Potatoes
Soy
Rice or other starches
Herbs / Spices
Fruits
Peanuts
Nuts
Seeds
Sprouts
Dairy
Eggs
Gluten
Wheat (breads, pasta)
Not applicable
Other
66
4.13 Select the beverages you drink every day or regularly.* This field is required.
Water
Soft Drink - sweet (tonic, pop)
Soft Drink - "diet" (tonic, pop)
Vitamin Water, Odwalla, etc.
Tea - Unsweetened
Sweet Tea or Coffee
Energy Drink (with stimulant)
Sports drink (Gatorade / others)
Beer
Wine
Coffee (No Sugar)
Coconut Drink -unsweetened
Milk (Cows Milk)
Soy Milk
Liquor
Other unsweetened beverage
Other sweetened beverage
I drink fluids infrequently
Other
67
4.14 Do you consume fermented foods?* This field is required.Pickles, Slaw, Yogurt, Raw Cheese, Kefir, Sauerkraut, Miso, Tempeh, Kimchi, Natto are examples.
Never
Rarely - Monthly at Most
Occasionally (Weekly)
A Few Times Each Week
Daily
With (almost) Every Meal
68
4.15 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
69
4.16 How do you use sugar in cooking?* This field is required.Do you use refined, raw or natural sugars?
Never Add Sugar
Follow the Recipe
Use Less than Recipe
I Sweeten My Foods
Add to Coffee & Tea Only
Crave Sweetened Foods
Use Stevia or Similar
Use Honey or Similar
Use a Zero Calorie Substitute
Other
70
4.17 How do you use salt?* This field is required.
Salt Restricted - per Doctor
Never Use / Add Salt
Use a Little Salt Only
Use Sea Salt
Shake Salt Liberally
Crave Salty Foods
Use Low Sodium Substitutes
Salt per Recipe
Other
71
4.18 How long has this been your eating style?* This field is required.Also - please indicate how it has changed - if you have changed your diet from the past.
< 1 Year
1 - 5 Years
5 - 10 Years
10 - 20 Years
My Entire Life
No Change in Quality
Improved Quality
Lowered Quality
Other
72
4.19 Please rate the health of your current eating style* This field is required.Consider your eating style over the past year.
Very Healthy
Healthy
Not Very Healthy
Unhealthy
Not Sure
73
CDA Score 4 - Food & Beverage
74
5.1 How often do you catch a cold?* This field is required..
Never / Almost Never
Rarely
Once a Year
Twice a Year
Often Catch a Cold
Often & They Last :(
75
5.2 How often do you get the Flu?* This field is required..
Never / Almost Never
Rarely
Once a Year
Twice a Year
Often
76
5.3 Do you get migraines or severe headaches?* This field is required..
Never / Almost Never
Rarely
Sometimes
Often / Weekly
Frequently / Daily
77
5.4 Do you take a Fish, Krill, Cod Liver Oil or Omega-3 Supplement?* This field is required.
YESNO
78
5.5 How much Omega-3 supplement do you take daily?* This field is required.1 capsule is about 1 gram.
< 1 Capsule
1 Capsule
2 - 4 Capsules
5 - 10 Capsules
> 10 Capsules (grams) Daily
79
5.6 Do you get dizzy or lightheaded?* This field is required.
Never / Not Applicable
When Hungry, Thirsty or Tired
Seldom - < Monthly
Occasionally - < Weekly
Frequently - Weekly
Daily
After Taking Medications
Other
80
5.7 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
From Menopause
Other
81
5.8 Do you take an antioxidant supplement* This field is required.Do NOT include Vitamin C when answering this question.
Yes - Daily AntiOx Supplement
Yes - Less Than Daily
In My Multivitamin Only
No Never
Not Applicable No Supplements
Not Sure
82
5.9 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
Past Issue - Resolved
Other
83
5.10 Do you have Anxiety?* This field is required.Answer this if your ANXIETY interferes with your daily living.
Never - Not Applicable
Almost Never
Seasonal Only
Infrequently
Frequently - Weekly
I'm Often Anxious
In the Past - Gone
84
5.11 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
85
5.12 Can you answer in 5 seconds - What was your dinner last night?* This field is required.
YESNO
86
5.13 Please describe your normal mood.* This field is required.Select up to the TOP 3 answers
Abandoned
Aggressive
Apathetic
Accomplished
Energetic
Confident
Hateful
Jealous
Hesitant
Hurt
Inquisitive
Joyful
Remorseful
Victimized
Thankful
Other
87
5.14 Toxins you have been exposed to.* This field is required.Choose those that may have caused you harm in the past and now.
None / Not Applicable
None Known
Mold
Metal Dust or Fume / Heavy Metals
Lead (Paint for Example)
Pesticides
Radiation (Natural, Medical/Treatment, Nuclear Plant)
Asbestos
Mercury
Fertilizers
Frequent X-Ray (Cat Scan, Chest or Teeth X-Rays)
Cleaning Agents
Infection from Exposure (TB, STD, Other)
Virus from Exposure (HIV/AIDS, HPV, Ebola)
Air Pollution
Water Contamination (E-Coli, Metals, Fluoride, Industrial Chemicals)
Fire/Combustion (Smoke inhalation)
88
5.15 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
None / Not Applicable
Other
89
5.16 What bugs have bitten you?* This field is required.Bugs carry disease. Think way back in time and consider where you have lived or travelled.
Tick
Bed Bug
Flea
Lice
Mosquitoes - Lots of Bites
Spider
Never Bitten
Other
90
5.17 Reproductive History: Select all that apply.* This field is required.Also, please provide an explanation in "Other / Explain."
None or Not Applicable
Pregnant Before 20
1st Pregnant After 30
Took DES
Had Preemie or Aborted Birth
Had Fertility Treatment
Had Hysterectomy
Other
91
5.18 What type of birth control do you use?* This field is required.Also, please provide an explanation in "Other / Explain."
None or Not Applicable
Birth Control Pill
Vaginal Ring
IUD
Birth Control Patch
Condoms
Day After Pill
Birth Control Implant
Birth Control Shot
Sponge
Spermicide
Sterilization
Vasectomy
Diaphragm
Cervical Cap
Pull Out Method
Outercourse or Abstinence
Other
92
5.19 Are you pregnant or planning to become pregnant?* This field is required.
YESNO
93
CDA Score 5 - Health Information
94
6.1 How old is your father?* This field is required.
Deceased
< 50
50 - 69
70 - 79
80 +
Not Sure
95
6.2 How old is your mother?* This field is required.
Deceased
< 50
50 - 69
70 - 79
80 +
Not Sure
96
6.3 How old was your father when he passed?* This field is required.
< 50
50 - 69
70 - 79
80 +
Not Sure
97
6.4 How old was your mother when she passed?* This field is required.
< 50
50 - 69
70 - 79
80 +
Not Sure
98
6.5 Select all chronic diseases either of your parents had.* This field is required.
None / Not Applicable
Cancer
Cardiovascular / Heart
Brain - Dementia
Diabetes
Respiratory
Gastrointestinal
Musculoskeletal
Autoimmune (Arthritis)
Mental Health
Not sure
Other
99
6.6 If siblings have died, please select the age ranges that apply.* This field is required.
Not Applicable
< 50
50 - 59
60 - 69
70 - 79
80 +
100
6.7 Select all chronic diseases your siblings have or had.* This field is required.
None / Not Applicable
Cancer
Cardiovascular / Heart
Brain - Dementia
Diabetes
Respiratory
Gastrointestinal
Musculoskeletal
Autoimmune (Arthritis)
Mental Health
Not sure
Other
101
CDA Score 6 - Family & History
102
7.1 Select any surgeries you have had - or are planning* This field is required.
Gall Bladder
Cataract
Eye (other)
Breast Biopsy
Cesarean Section
Carotid Blockage
Coronary Bypass
Joint Replacement
Lower Back
Skin Graft
Hysterectomy
Hernia
Mastectomy
Colon
Prostate
Tonsils
Thyroid
Tumor Removal
None / Not Appicable
Other
103
7.2 Metabolic / Endocrine: Select any disease / problems you CURRENTLY have.* This field is required.Select ALL that apply to you
Diabetes (Type 1)
Diabetes (Type 2)
Hypoglycemia (sweats, shaky)
Pre-Diabetes
Hypothyroidism
Hyperthyroidism
Endocrine Problems
Polycystic Ovarian Syndrome
Infertility
Sudden Weight Changes
Anorexia
Bulimia
Eating Disorder (not listed)
Hair loss or Thinning
Constant or Frequent Hunger
Blurred Vision (sometimes)
Unusual Thirst
None / Not Applicable
Other
104
7.3 Endocrine / Diabetes: Are you taking any of these drugs?* This field is required.Include procedures. Select ALL that apply to you
Metformin
Insulin Therapy
Sulfonylureas. ...
Meglitinides. ...
Thiazolidinediones. ...
DPP-4 inhibitors. ...
GLP-1 receptor agonists. ...
SGLT2 inhibitors. ...
Surgery
Thyroid Meds
Hormones
Not Sure
None / Not Applicable
Other
105
7.4 Respiratory: Select any disease / problems you CURRENTLY have.* This field is required.Select ALL that apply to you
Emphysema
COPD
Persistent Cough
Wheezing / Shortness of Breath
Chronic Sinusitis
Pneumonia
Tuberculosis Exposure
Bronchitis
Sleep Apnea
Asbestos Exposure
Lung Cancer
Asthma
Sleep Apnea
None / Not Applicable
Other
106
7.5 Cancer: Select any disease / problem you CURRENTLY have.* This field is required.Select ALL that apply to your
Lung Cancer
Breast Cancer
Colon Cancer
Ovarian Cancer
Uterine Cancer
Pancreatic Cancer
Prostate Cancer
Skin Cancer (non-melanoma)
Melanoma
Brain
None/ Not Applicable
Other
107
7.6 Cancer: Are you taking any of these drugs / treatments?* This field is required.Select ALL that apply to you
Chemotherapy
Radiation
Surgery
Immunotherapy "MABs"
Avastin
Hormone Therapy (SERMs, etc.)
Alternative / Natural Therapies
Steroids (Prednisone, etc)
None / Not Applicable
Other
108
7.7 Gastrointestinal: Select any disease / problems 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
Stomach Ulcers
None / Not Applicable
Other
109
7.8 Gut: Are you taking any of these drugs?* This field is required.Select ALL that apply to you
Pepto Bismol
Antacids (Tums etc.)
Proton Pump Inhibitor
H2 (Hydrogen) Blocker
Probiotic
Vitamin C
Apple Cider Vinegar
Laxative
Linzess
Alternative / Natural Therapy
None / Not Applicable
Other
110
7.9 Eyes: Select any disease / problem you CURRENTLY have.* This field is required.Select ALL that apply to you
Glaucoma
Macular Degeneration - Wet
Macular Degeneration - Dry
Cataract Surgery
Cataract
Shingles
Diabetic Retinopathy
Eye Injections
Dry Eye
Sudden Vision Loss
Loss of Side / Peripheral Vision
CMV Retinitis
Diabetic Macular Oedema
Eye Floaters or Eye Flashes
Keratoconus
Low Vision
Ocular Hypertension
Uveitis
None / Not Applicable
Other
111
7.10 Eyes: Are you taking any of these drugs?* This field is required.Select ALL that apply to you
Glaucoma eye drops
Dry Eye Drops
Macular Disease Drops
Lucentis or other eye injection
Cataract Surgery (Past)
Surgery (not cataract)
Diabetic Retinopathy Drop/Inject
Laser Treatment
Oral medication
Alternative / Natural Treatment
None / Not Applicable
Other
112
7.11 Skin: Select any disease / problem you CURRENTLY have.* This field is required.Select ALL that apply to you
Rashes/Eczema
Non Cancerous Skin Mark
Skin or Tissue Ulcers
Sores/Cold Sores
Dermatitis or Hives
Psoriasis (type of skin rash)
Numbness
Melanoma
Skin Cancer (not melanoma)
Local Discoloration
Changing Mole
Slow Healing/Easy Bruising
Rosacea (red skin)
Sun Burn/Blistering (any time)
Shingles
Lupus
Rubella (Measles)
Chronic Acne
Sores in Nose
Dry Skin Patch/Unable to Heal
Genital / STD Sores
None / Not Applicable
Other
113
7.12 Skin: Are you taking any of these drugs?* This field is required.Select ALL that apply to you
Topical Steroid
Oral Steroid
Anti-Viral (for Shingles, etc.)
Antihistamine (Allegra, Claritin..)
Aloe Vera or other "ointment."
Antibiotic topical
Antibiotics (doxycycline, etc.)
For Acne - an Oral Drug
Beta blockers
Fungus treatment
Surgery
Radiation
Light / Infrared
Natural / Alternative
None / Not Applicable
Other
114
7.13 Musculoskeletal: Select any disease / problems you CURRENTLY have.* This field is required.Select ALL that apply to you
Arthritis
Rheumatoid Arthritis
Osteopenia or low bone density
Osteoporosis
Chronic Pain (non-specific)
Chronic Back Pain
Gout (pain in toe or lower joint)
Joint Pain
Muscle Pain
Jaw Pain
Neck Pain
Tendonitis
Scoliosis (twisted spine)
Broken Bone
Carpal Tunnel Syndrome
Ruptured/Herniated Disc
Fibromyalgia
None / Not Applicable
Other
115
7.14 Musculoskeletal: Do you use any of these remedies?* This field is required.Select ALL that apply to you
NSAIDs / OTC Pain Meds
Ice or Heat
Topical Analgesics
Physical / Occupational Therapy
Manipulation / Chiropathic
Strength Training / Stretching
Massage
Acupuncture or pressure
Relaxation or Meditation
Bio / Neurofeedback
Aspirin
None / Not Applicable
Other
116
7.15 Heart: Select any disease / problem you CURRENTLY have.* This field is required.Select ALL that apply to you
Blood Clots or Clotting Issues
High Blood Pressure
Heart Attack
Irregular Heart Beat
Abnormal Cholesterol
Stroke
Inflammation
Swelling of Hands/Feet/Ankles
Rapid Heart Rate (Tachycardia)
Chest Pain/Tightness (Angina)
Low Blood Pressure
Frequent Dizziness
Fainting
Cold Hands/Feet
Pain in legs/feet/extremities
Mitral Valve Prolapse
Rheumatic Fever
Infection
None / Not Applicable
Other
117
7.16 Heart: Are you taking any of these drugs?* This field is required.Select ALL that apply to you
Statins / Other Cholesterol
Aspirin
Anti-clotting / Blood Thinner
Beta-blockers
ACE inhibitors
Blood Pressure - Diuretics
Angiotensin Receptor Blockers
Calcium Channel Blockers
Not Sure
Alternative / Natural Treatment
None / Not Applicable
Other
118
7.17 Brain: Select any disease / problem you CURRENTLY have.* This field is required.Select ALL that apply to you
Dementia, Alzheimer's ...
Brain Infection (Meningitis ...
Brain Injury (TBI, PTSD...)
Concussion (in the past)
Depression, Anxiety ...
Headaches, Migraines ...
Memory Loss...
Cognitive Impairment
Mood Disorder ...
Glaucoma
Neurodegenerative Disease
Seizures
Shaking, Tremors, Unsteadiness
Sleep Issues: Lack of Sleep
Stroke, Aneurysm, or Vascular Disease
Tumors, Masses
Easy Confusion
None / Not Applicable
Other
119
7.18 Brain: Are you taking any of these drugs?* This field is required.Select ALL that apply to you
Namenda
Aricept
Stimulants
Antidepressants
Antipsychotics
Mood Drugs
Deprssion Meds
Anxiety Drugs
Alzheimer's Meds
Parkinson's Meds
Alternative / Natural
Not Sure What I'm Taking
None / Not Applicable
Other
120
7.19 Autoimmune & Inflammation: Select any disease / problems you CURRENTLY have.* This field is required.Select ALL that apply to you
Skin Disorder / Rashes
Rheumatoid Arthritis
Fatty Liver
Multiple Sclerosis
Immune Deficiency Disease
Low Vitamin D
Severe Infectious Disease
Poor Immune Function
Chronic Joint / Other Pain
Multiple Chemical Sensitivities
Thyroid / Energy Issues
Gut Issues
Adrenal Fatigue
Brain Fog
None / Not Applicable
Other
121
7.20 Inflammation: Are you taking any of these "Biologic" or anti-inflammatory drugs?* This field is required.Select ALL of these immunomodulatory drugs that apply to you
Drug Name Ends "MAB"
Drug Name Ends "NIB"
Abatacept (Orencia)
Adalimumab (Humira)
Anakinra (Kineret)
Certolizumab (Cimzia)
Etanercept (Enbrel)
Golimumab (Simponi}
Infliximab (Remicade)
Rituximab (Rituxan)
Tocilizumab (Actemra)
Tofacitinib (Xeljanz)
Tocilizumab (Actemra)
Natural / Alternative
None / Not Applicable
Naproxen
Other
122
7.21 What is your blood pressure - on average? Please answer for your systolic (upper number) only.* This field is required.
< 80
80 - 100
100 - 120
120 - 150
150 - 180
> 180
Not Sure
123
7.22 What is your height - in INCHES?* This field is required.60 inches = 5 feet; 72 inches = 6 feet
124
7.23 What is your weight - in POUNDS?* This field is required.2.2 pounds = 1 kilogram
125
7.24 What is waist circumference (belt size) in INCHES?* This field is required.
126
7.25 Describe Your Body Type* This field is required.SELECT THE BEST ONE ONLY
Thin
Average
Overweight
Muscular
Not Sure
127
7.25a - BMI Calculation
128
7.25b - Waist to Height Ratio
129
7.26 WHAT IS YOUR A1C? This is a blood sugar biomarker. Please enter your most recent value by selecting the right range. Estimate your value if you think you know it based on testing.* This field is required.
< 4
4 - 4.9
5.0 - 5.7
5.7 - 6.4
6.5 - 8.0
> 8.0
Not Sure
130
7.27 And lastly - Yes - Please describe your bowel movements.* This field is required.Your stools tell a story about digestion, absorption, detoxification - and overall health. Answer ALL that apply.
Frequency: ≥1 time per day
Frequency: >3 times per week
Frequency: ≤3 times per week
Frequency: ≤1 times per week
Color: Brown
Color: Black
Color: Light (Grey)
Frequently Constipated
Frequent Diarrhea
Frequent Loose Stools
Blood in Stools
I Don't Observe My Stools
Other
131
CDA Score 7 - Body Systems
132
8.1 Our program works when we take the time to know you and all of your unique circumstances. Are you willing to spend the time required, working with our team, to improve your health?* This field is required.
YESNO
133
8.2 The major contributors to chronic disease are food and lifestyle habits. Are you willing to keep a food journal for 4-7 days every 3 months? * This field is required.
YESNO
134
8.3 Please explain why you would like to participate in this program, your HEALTH HISTORY, and also please note your motivations to change.* This field is required.MOTIVATIONS: Family, Wedding, Energy, Grand kids - are examples
135
Chronic Disease Assessment TOTAL Score:
136
CDA GRADE A! You live a healthy life. Next take the Chronic Disease Temperature to make sure your blood is telling the same healthy story.
137
CDA GRADE B. You have some chronic health risks. Consider working with one of our coaches to improve your risk grade (health) and take the Chronic Disease Temperature to help determine the best path to improve your health..
138
CDA GRADE C. You have a bunch of chronic health risks that could impact the quality of your health if they haven't already. Strongly consider working with one of our coaches to improve your risk grade (health) and take the Chronic Disease Temperature to help determine the best path to improve your health..
139
CDA GRADE D. You have many chronic health risks that could impact the quality of your health significantly if they haven't already. Strongly consider working with one of our coaches to improve your risk grade (health) and take the Chronic Disease Temperature to help determine the best path to improve your health.
140
CDA GRADE F! You have an extreme number of chronic health risks that could impact the quality of your health significantly if they haven't already. Strongly consider working with one of our coaches to improve your risk grade (health) and take the Chronic Disease Temperature to help determine the best path to improve your health.
141
CDA GRADE - Please Click "SUBMIT" (Bottom Right). You will be provided with a detailed report, shortly, showing your risks. You will also be directed to a site that offer services to explain your risks and help you develop a comprehensive care plan to overcome these risks in a logical and manageable way.Click SUBMIT on the lower right corner to save and exit.
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