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BECOME A PARTNER
Practitioners
Take Nutrition Quiz
First a few questions about you:
My name is:
My gender is:
Age:
My concerns or health goals are:
Please Choose 3 to 5 goals
Improve Cognition
Bone Protector
Recover Post-workout
Boost Pre-workout
High Blood Pressure
High Cholesterol
Strengthen Hair and Nails
Boost Energy
Elevate Mood
Joint Health
Anxiety/Stress
Boost Immunity
Improve General Health
Weight Loss
Eye Health/Strain
Digestion
Heart Health
Where do you live?
Country
Afghanistan
Albania
Algeria
American Samoa
Angola
Anguilla
Antartica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ashmore and Cartier Island
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czeck Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Europa Island
Falkland Islands (Islas Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City)
Honduras
Hong Kong
Howland Island
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Ireland, Northern
Israel
Italy
Jamaica
Jan Mayen
Japan
Jarvis Island
Jersey
Johnston Atoll
Jordan
Juan de Nova Island
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Man, Isle of
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Midway Islands
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcaim Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romainia
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Scotland
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich Islands
Spain
Spratly Islands
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Tobago
Toga
Tokelau
Tonga
Trinidad
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
USA
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands
Wales
Wallis and Futuna
West Bank
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Province/State
Next
Lifestyle
CHOOSE ALL THAT APPLY
Diet
IN THE AVERAGE DAY
I consume 2 or more servings of seafood in the average week
I consume 5 or more servings of fruits and vegetables
I eat at least 3 meals
Continue
1
of 3
Lifestyle
IN THE AVERAGE WEEK
I spend less than 20 minutes per day in direct sunlight or suffer from Seasonal Affective Disorder
I get the recommended 75-150 minutes of aerobic exercise every week
I smoke cigarettes or am exposed to second-hand smoke regularly
Back
Continue
2
of 3
Sleep, Energy, Stress
IN THE AVERAGE WEEK
I am under high levels of mental/ emotional stress
My daytime energy is 8+ on a 10 point scale
I get at least 6 hours of restful sleep each night
Back
3
of 3
Do you have any dietary restrictions?
Select all that apply to you
Yes
Please list your dietary restrictions and food allergies
No
Next
I am a:
None
Vegan
Vegetarian
Next
Health History
What are your current medical conditions? (skip if none)
What are your current medical conditions? (skip if none)
Migraines
Chronic Headaches
Cognitive Decline
Stroke
Bipolar Disorder
Depression
Anxiety
Heart Failure
High Cholesterol
High Blood Pressure
Allergies
COPD
Asthma
Chrohn’s/ Ulcerative Colitis
IBS
Celiac Disease
Diarrhea/ Constipation
Osteoporosis
Chronic Pain
Arthritis or Muscle Cramps
Autoimmune Disease
Cancer
Diabetes
Other
Next
Medications
What current medications do you take regularly? (skip if none)
What current medications do you take regularly? (skip if none)
Anti-Obesity (Orlistat (Xenical))
Hydralazine (Apresoline)
Cardiax Glycosides (ex. Digoxin, Lanoxin)
Blood Pressure Lowering Duretics (ex. Lasix, Hyrdrocholorothiazide, Spironolacatone, Furosemide, Chlothalidone)
Cholesterol Reducing Statin Drugs (ex. Lipitor, Crestor, Zocor)
Proton Pump Inhibitors
H2 Blockers (ex. Pepcid, Zantac, Tagamet)
Oral Contraceptives
Anti-anxiety or anti-depressants
Anti-coalgulants
Valproic Acid
Aspirin
NSAIDS (Ibuprofen, Motrin, and Naproxen)
Acetaminophen (Tylenol)
Acetaminophen (Tylenol)
Any Antibiotic
Other
Next
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