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Member Name:
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Weight (lbs):
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Resting Heart Rate:
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Present blood pressure:
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My overall energy level: (1-10) Terrible to fantastic
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My present activity level: (1-10) Not active to very active
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My sex drive or libido: (1-10) Not active to very active
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I feel exhausted by mid day: (1-10) Wiped out ot endless energy
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I am happy with my skin: (1-10) Not at all to it's fantastic
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I get respiratory infections(Colds, runny nose, pneumonia)
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I am happy with my body shape: (1-10) Not at all to it's fantastic
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I have allergies (Pollen, dogs, etc.): (1-10) Not active to very active
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My pattern of hair loss or thinning: (1-10) Significant hair loss to not at all
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I have back pain, chronic joint pain or stiffness:
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Pain Level: (1-10) Absolute misery to very little
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I have trouble sleeping: (I can't sleep a bit to sleep very well)
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My day time vision is: (1-10) Terrible to fantastic
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My night time vision is: (1-10) Terrible to fantastic
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My up close vision is: (1-10) Terrible to fantastic
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I rate my memory as: (1-10) Terrible to fantastic
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I would rate my diet as: (1-10) Terrible to fantastic
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Summary:
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Weight:
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Blood Pressure:
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Resting Heart Rate:
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Score out of 160:
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Percentage:
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I am happy with my body shape (1-10) (Not at all to I look amazing)
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I am happy with my body shape (1-10) (Not at all to I look amazing)
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I am happy with my skin: (1-10) Not at all to it's fantastic
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