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Take this short 15 question quiz to find out!
Please answer the following questions.
1. What is your first name?
2. Are you male or female? Male Female
3. How old are you?
4. Do you suffer from any of the following?
Stress Insomnia Increased or Poor Appetite
Hypertension Elevated Cholesterol Decreased Energy
Chronic Fatigue Frequent Headaches Recent and/or unexplained
      weightloss or gain.
Depression Other  
5. Have you ever been medically diagnosed with a disease? Yes No
6. If so, which disease and when were you first diagnosed?
7. Have you or any of your close relatives ever suffered from any of the following?
Cancer Heart Disease Stroke
Obesity Hypertension Anxiety
Depression Other Mental Disorder Other  
8. Do you smoke? Yes No
9. Are you currently trying to either lose or gain weight? Yes No
10. Have you tried popular diets, products and/or exercise programs that either did not work for you or failed to keep off the weight permanently? Yes No
11. If so, which one(s)?
12. Are you concerned about the future of your health, your quality of life and/or longevity prospects? Yes No
13. Would you like to learn more on how to optimize your health and prevent future disease? Yes No
14. Would you like someone from our clinic to contact you to arrange a free in-clinic consultation? Yes No
15. If so, please enter your email address and phone number.
Phone Number:
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