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Health Assessment Form

Personalized Health Assessment

Discover your nutritional needs with our comprehensive health evaluation

Step 1 of 6

Personal Information

Full Name *

Email Address *

Phone Number

Age *

Gender *

Height (cm) *

Weight (kg) *

Lifestyle & Dietary Habits

How would you describe your diet? (Select all that apply)

Vegetarian Vegan Non-Vegetarian Eggetarian Dairy-free Gluten-free

Fruits & Vegetables per day

Fish/Seafood per week

Milk/Dairy per week

Sunlight exposure per week

Sleep per night

Do you smoke?

Yes No

Do you consume alcohol?

Yes No

Health & Medical History

Do you have any of the following conditions? (Select all that apply)

Diabetes High Blood Pressure Thyroid Disorder Heart Disease Kidney Disease Digestive Issues None

Are you currently taking any medications or supplements?

Yes No

Are you pregnant or breastfeeding?

Yes No Not Applicable

Symptom Assessment

Please check any symptoms you have experienced in the past 3 months and rate their severity:

Energy & General Wellbeing

Fatigue / Low Energy

Weakness

Dizziness

Hair, Skin & Nails

Hair Loss

Brittle Nails

Dry Skin

Bone & Joint Health

Bone Pain

Muscle Cramps

Mental Health

Mood Swings

Poor Memory/Concentration

Goals & Preferences

What are your main health goals? (Select all that apply)

Boost Energy Improve Immunity Better Skin/Hair/Nails Bone/Joint Health Weight Management General Wellness

Do you have any allergies or ingredient preferences?

Consent & Submit

I understand that this assessment is for informational purposes only and is not a substitute for professional medical advice. I consent to the use of my information for personalized product recommendations.

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