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Scientifically formulated and clinically tested nutritional supplements

Health Scan Survey

The information you provide on this site is held in the strictest confidence allowed by law. It is considered in the same legal arena as provided for in Doctor-Patient confidentiality relationships. This information will never be disclosed or shared with anyone not directly involved in determining the appropriate response without your express written consent.

You should fill out this survey if you are interested in your health. Our free response provides general information that you may find of value and interest. At the end of the survey - you will get an immediate "scoring" and explanations of how supplements may help you. These results (including the details of your survey) will be emailed to you as well.

Please answer ALL questions as honestly as possible. You will be prompted for any missing required data.

PERSONAL INFORMATION:

First name

Last name

Address

City

State

Zip

Phone

Email address

1. Height:

feet inches


2. Current Weight (pounds):

3. Desired Weight (pounds):

4. Body Frame:	Small	Average	Large

5. Age (years):

6. Sex:

Male

Female

7. Race:

Caucasian
Hispanic
African American
Asian
Other

YOUR LIFESTYLE:

8. Regarding your weight, do you consider yourself:
Appropriate weight
Under weight
5-10 pounds overweight
10-25 pounds overweight
more than 25 pounds overweight

9. Are you trying to build muscle?
Yes     No

10. Are you trying to:
Lose weight
Gain weight
Neither gain nor lose

11. What is your activity level?:
Extremely active, I exercise more than 4 times per week (30 min or more)
Moderately active, I exercise 2-4 times per week (30 min or more)
Average activity level, I exercise 1-2 times per week (30 min or more)
Minimally active, I exercise 1 time per week (30 min or more)
Sedentary, I don't exercise at all

12. How do you currently feel about your health?:
perfect health
very good health
average health
below average health
unhealthy

13. How is your diet?
I eat a well-balanced diet from all the food groups including fruits and vegetables daily.
I eat well most of the time ie 5/7 days
I eat well about half of the time
I often eat on the run occasionally consuming fast food products
I often eat fatty meals, candy, processed foods and fast foods

14. Please provide a general idea of your diet:
a) Breakfast:

b) Lunch:

c) Dinner:

d) number of snacks and what kinds:

e) average amount of calories consumed per day (if you know):

15. How many fruit and vegetable servings do you eat per day?
greater than 5 cups or servings
at least 3 and up to 5 cups or servings
at least 1 and up to 3 cups cups or servings
minimal to no fruits or vegetables

16. How do you prepare the vegetables you eat?
raw
steamed
boiled
baked
fried

17. How many times do you eat processed meats or smoked foods (salami, hot dogs, bacon, ham, corned beef, smoked cheese or fish)?
never
rarely (4 times/year)
once per month
once per week
more than twice per week

18. How often do you eat "fast food" (McDonalds, Burger King, etc.)?
never
twice per year
once per month
once per week
everyday

19. How do you rate your current stress level?
no stress, life is perfect
minimal stress
average amount of stress
moderate amounts of stress, cannot seem to stay ahead
severe stress

20a) What kind of work do you do?

20b) Do you enjoy it?
Yes     No

21. How satisfied are you with your life?
perfectly satisfied, life is great
very satisfied
average satisfaction
moderately dissatisfied
unsatisfied

22. Marital Status:
single
married
divorced
married multiple times

23. How many children do you have?
none
1-2
3-4
5-6
more than 7

24. How do you rate your current energy level?
extremely energetic
have enough energy for most things
average energy level
low energy level, I feel like I am dragging much of the time
little or no energy for most things

25. How much sleep do you get each night (on average)?
10-12 hours per night
8-9, hours per night
6-7, hours per night
4-5, hours per night
less than 4 hours per night

26a. Do you smoke or use tobacco products?
Yes     No
26b. If yes, how much?
One pack or less per day
More than one pack per day
Chew tobacco
26c. If yes, for how long?
more than 20 years
16 to 20 years
11 to 15 years
5 to 10 years
less than 5 years

27. Are you exposed to second hand smoke at least twice a week?
Yes     No

28. How much alcohol do you drink?
none
less than 1 drink per month
1 drink per week
2-3 drinks per week
1 drink per day
2 drinks per day
1/5 of alcohol or more per day

29. Are you an alcoholic?
Yes     No     Recovering

30. Do you add salt to your meals?
never
rarely (once per month)
sparingly, but most meals
I add salt to most things
I add salt to everything

31. Do you use medications or drugs?
Yes     No
If yes, how often and which meds/drugs:

32. Do you have any of these major medical problems (check all that apply)?
None
High Blood Pressure
Heart Disease
Seizure Disorders
Asthma
Diabetes
Stroke
Cancer
High Cholesterol
Arthritis
Liver Problems
Other(s) please specify below:

33. Are you allergic to any medications?
Yes     No
If yes, please list which ones:

34. Have you ever been allergic to any herbs?
Yes     No

35. Do you have any environmental allergies (ie dust, mildew, etc.)?
Yes     No

36. What is your caffeine intake/day?
none
1-2 cups per day
2-3 cups per day
3-4 cups per day
more than 4 cups per day

37. Do you consume products that contain nutrisweet/saccharin or aspartame?
Yes     No
If so, how much and what particular products (ie diet coke, pepsi, sugerless gum, equal, nutrisweet etc.):

38. Do you currently take vitamin, mineral or herbal supplements?
Yes     No
If so, please list which ones and how dosage below:

39. How often do you travel by plane?
never
less than 4 times per year
once per month
2-5 times per month
more than five times per month

40. At what altitude do you live?
at or below sea level
100-500 feet above sea level
500-1000 feet above sea level
1000-3000 feet above sea level
greater than 3000 feet above sea level

41. What is the approximate pollution level where you spend most of your time?
little amounts of smog and pollution
moderate amounts of smog and pollution
severe amounts of smog and pollution

42. How much sun exposure do you get (hourly increments minimum)?
very little, less than once per month
mild amount, once per week
average amount, 2-3 times per week
moderate amount, 4-5 times per week
significant amount, daily exposure

43. How much water do you drink?
none
1-3 eight ounce glasses per day
4-6 eight ounce glasses per day
7-9 eight ounce glasses per day (this is the recommended amount)

44. What is your blood type?
Type A
Type B
Type AB
Type O

45 thru 50 for women only:

---45. Do you have menstrual cycles?
Yes     No

---46. When/If you menstruate, are your periods:
regular-monthly
irregular

---47. When/If you menstruate, is your flow:
light
normal
heavy

---48. Are you pregnant?
Yes      No

---49. Are you lactating?
Yes     No

---50. Are you currently taking iron supplements?
Yes     No

Occasionally (10-12 times per year) Dr. Seidman provides interesting 1-3 page medical science updates/news related to your health. These are provided to you at no charge. Your email address is considered confidential and is NEVER shared, sold or passed out in any way shape or form. We would like to provide this information to you. Is this okay?
Yes No

Please let us know how you heard about us (check all that apply):
A Friend (name below if you wish)
WMGC Radio Ad Jim Harper - Linda Lanci
Family member (name below if you wish)
Work Associate (name below if you wish)
Searching the Web
Another Web Site (name below if you wish)
Magazine Advertisement
Henry Ford Health System
Your Doctor (name below if you wish)
Symposium (name below if you wish)
Shop America Network
Natural Awakenings Magazine
Book - Save Your Hearing Now
NPR - National Public Radio
Other (describe below if you wish)

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