WEIGHT LOSS MADE EASY™️

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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?
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1.2 What is your date of birth? mm/dd/yyyy* This field is required.
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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
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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
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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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1.12 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
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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
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1.14 How motivated are you to become more healthy?* This field is required.
Highly motivated
Motivated
Neutral
Not motivated
Highly unmotivated
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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
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CDA Score 1 - Personal Information
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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
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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
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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
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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
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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
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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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2.11 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
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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
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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
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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
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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
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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
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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
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CDA Score 2 - Lifestyle Information
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3.1 How often do you BRUSH your teeth?* This field is required.
Never
Seldom
Occasionally
Daily
Twice Daily
After Every Meal
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3.2 How often do you FLOSS your teeth?* This field is required.
Never
Seldom
Occasionally
Daily
Twice Daily
After Every Meal
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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
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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
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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
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3.7 Do you have dental implants, root canals, or dentures?* This field is required.
YESNO
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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
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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
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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
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CDA Score 3 - Oral Health
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
50
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
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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
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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
53
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
54
CDA Score 4 - Food & Beverage
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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 :(
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5.3 Do you get migraines or severe headaches?* This field is required..
Never / Almost Never
Rarely
Sometimes
Often / Weekly
Frequently / Daily
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5.4 Do you take a Fish, Krill, Cod Liver Oil or Omega-3 Supplement?* This field is required.
YESNO
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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
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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
60
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
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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
62
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
63
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
64
5.12 Can you answer in 5 seconds - What was your dinner last night?* This field is required.
YESNO
65
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
66
CDA Score 5 - Health Information
67
6.1 How old is your father?* This field is required.
Deceased
< 50
50 - 69
70 - 79
80 +
Not Sure
68
6.2 How old is your mother?* This field is required.
Deceased
< 50
50 - 69
70 - 79
80 +
Not Sure
69
6.3 How old was your father when he passed?* This field is required.
< 50
50 - 69
70 - 79
80 +
Not Sure
70
6.4 How old was your mother when she passed?* This field is required.
< 50
50 - 69
70 - 79
80 +
Not Sure
71
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
72
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 +
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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
74
CDA Score 6 - Family & History
75
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
76
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
77
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
78
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
79
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
80
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
81
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
82
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
83
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
84
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
85
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
86
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
87
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
88
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
89
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
90
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
91
7.22 What is your height - in INCHES?* This field is required.60 inches = 5 feet; 72 inches = 6 feet
92
7.23 What is your weight - in POUNDS?* This field is required.2.2 pounds = 1 kilogram
93
7.24 What is waist circumference (belt size) in INCHES?* This field is required.
94
7.25 Describe Your Body Type* This field is required.SELECT THE BEST ONE ONLY
Thin
Average
Overweight
Muscular
Not Sure
95
7.25a - BMI Calculation
96
7.25b - Waist to Height Ratio
97
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
98
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
99
CDA Score 7 - Body Systems
100
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
101
8.3 Please explain why you would like to participate in this program and also please note your motivations to change.* This field is required.MOTIVATIONS: Family, Wedding, Energy, Grand kids - are examples
102
Chronic Disease Assessment TOTAL Score:
103
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.
104
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..
105
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..
106
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.
107
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.
108
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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