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Health Evaluation Form

Please Complete Your Free Health Evaluation

Thank you for choosing The Science of Raw Superfoods for Change Life Coaching Program. You are about to embark on a journey of self-discovery. We have some important questions that you should answer thoroughly so that we can assist you to the best of our ability.

CONFIDENTIAL COMPREHENSIVE QUESTIONNAIRE: HEALTH, DIET & ENERGY EVALUATION / LIFESTYLE ANALYSIS FORM.

Please CHECK any that you feel apply:
Health Evaluation Section:

1. How would you describe your weight concerns?

I am significantly overweight (more than 20 pounds).
My weight is like a yo-yo.
I am under weight.
My weight is not an issue for me.

2. How would you characterize the stress in your life?

Stress is ruining my life.
Parts of my life are stressful.
I don't let stress get the best of me.
My life isn't particularly stressful.

3. How would you rate your diet and eating habits?

Poor. I could do a lot better.
So-so. I'm on the right track, but I'm far from perfect.
Okay. I eat healthy most of the time.
Great. I eat well.

4. Caffeine Intake

Do you drink Coffee or any other caffeinated beverage or substance?
If yes, how many cups per day?
For How long?

5. Drug & Alcohol Use:

Do you or did you in the past ever drink alcohol on a regular basis?
If yes, when?
For how long? How much?

Do you or did you ever use non-prescription drugs?
If yes, which specific drugs?
When? For how long?

6. Prescription medicine:

Are you currently taking any medications? If yes, which ones and why:

Are there any medicines, herbs or supplements you have taken a lot of in the past?
If yes, which ones:
How much?
What was the purpose?

7. How would you rate your physical activity level?

Sedentary
Moderate
Light
Active

8. How would you rate the health and conditioning of your heart?

Very Poor. Compromised heart function due to heart attack or other health condition.
Poor. Hardly ever walk or exercise.
Fair. Sit at a desk/elsewhere most days; occasionally walk or exercise.
Very Good. Hike, bike, or vigorous exercise daily.

9. Are you concerned about any of these health conditions? (Check all that apply.) 10. Please confirm your information:

Age: Gender: M F
First Name:
Last Name:
E-mail:

11. Goals & Expectations:

What are your expectations in seeking The Science of Raw Superfoods for Change Life Coaching Program?

Note: If you answered yes to more than 5 questions you are most likely loaded with toxins throughout your organs, cells, blood and body and could gain a great deal from participating in this program

Take Control of Your Health with
The Science of Raw Superfoods for Change Life Coaching Program
Online Life Coaching program with Dr. Shahila Rose
For just only $9.95 month your credit card will be charged when you subscribe and at the beginning of the month
You may cancel at any time, other than the minimum one month charge of $9.95 which is non-refundable.

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