Free Health Consulting

VITAMIN FOR LIFE MANAGEMENT & CONSULTING, INC.
and YOUNGER AGAIN
Presents a

FREE HEALTH CONSULTATION

THE INFORMATION PROVIDED BELOW IS FOR EDUCATIONAL PURPOSES ONLY AND UTILIZES INFORMATION FROM LEADING HEALTH TEXTS AND EXPERTS TO AID YOU IN CREATING A PROGRAM TO PROMOTE GOOD HEALTH.*

IN ORDER TO HELP YOU ASSESS YOUR REQUIREMENTS, PLEASE ANSWER THE QUESTIONS BELOW AS ACCURATELY AS POSSIBLE. IF UNSURE, LEAVE BLANK.
Your personal information is strictly confidential with Vitamin for life. None of the information will ever be disclosed from Vitamin for life.

BIRTH DATE (MONTH/DAY/YEAR)

Male Female WEIGHT (POUNDS) lbs.

HEIGHT (FEET, INCHES)

LDL CHOLESTEROL HDL CHOLESTEROL

RATIO

BLOOD PRESSURE (SYSTOLIC-HIGH NUMBER)
BLOOD PRESSURE (DIASTOLIC-LOW NUMBER)

NON-FASTING GLUCOSE (BLOOD SUGAR)

1) HOW WOULD YOU RATE YOUR OVERALL HEALTH?
(1-10, 10 BEING EXCELLENT)

2) PLEASE LIST HOW MANY TIMES PER WEEK YOUR OVERALL EXERCISE PROGRAM PROVIDES AT LEAST 20 MINUTES OF AEROBIC EXERCISE (WALKING, RUNNING, SWIMMING, AEROBICS, ETC)

3) PLEASE LIST MEDICATIONS TAKEN AND FOR WHAT PURPOSE

NAME OF DRUG STRENGTH # PER DAY PURPOSE

4) PLEASE RATE YOUR DIETARY INTAKE BELOW:

ESTIMATED CALORIES CONSUMED (PER DAY)

# OF MEALS CONSUMED

HOW MUCH FAT DO YOU CONSUME A DAY 1-5 (1 being low)
HOW MANY CARBOHYDRATES DO YOU CONSUME A DAY 1-5 (1 being low)

5) CARDIOVASCULAR-PLEASE PROVIDE INFORMATION BELOW ON ANY PROBLEMS YOU HAVE HAD WITH YOUR HEART

6) MEDICAL HISTORY-PLEASE ADVISE IF YOU HAVE A DOCTOR AND THE LAST CHECK-UP YOU HAD

7) PLEASE LIST ALL MEDICAL CONDITIONS FOR WHICH YOU HAVE DIAGNOSED (past or present)

8) ALCOHOL USE-PLEASE INDICATE # OF DRINKS CONSUMED PER WEEK

9) PLEASE LIST SMOKING HISTORY, AND IF YOU STILL SMOKE (# OF PACKS)

10) FAMILY HISTORY-PLEASE INDICATE BELOW IF ANY PARENTS, GRANDPARENTS, OR SIBLINGS HAVE OR HAD BEEN DIAGNOSED WITH HYPERTENSION (HIGH BLOOD PRESSURE) AND IF THEY WERE PRESCRIBED MEDICATION.

11) PLEASE LIST IF ANY FAMILY MEMBERS HAVE HAD A STROKE, AND THEIR RELATIONSHIP TO YOU.

12) PLEASE LIST IF ANY FAMILY MEMBERS HAVE HAD A HEART ATTACK, AND THEIR RELATIONSHIP TO YOU.

13) PLEASE LIST IF ANY FAMILY MEMBERS HAVE HAD DIABETES (TYPE), AND THEIR RELATIONSHIP TO YOU.

14) PLEASE LIST FAMILY MEMBERS THAT HAVE HAD CANCER, AND THEIR RELATIONSHIP TO YOU.

15) PLEASE RATE YOUR LEVEL OF HAPPINESS. (1-10, 10 BEING VERY HAPPY)

16) STRESS ASSESSMENT (1-10)(1-VERY LOW STRESS, 10-EXCESSIVELY STRESSED)

17) PLEASE LIST ANY SYMPTOMS OR CONDITIONS NOT MENTIONED ABOVE:

18) PLEASE LIST ALL DIETARY SUPPLEMENTS (VITAMINS, MINERALS, ETC...) BELOW

19) PLEASE LIST YOUR EMAIL ADDRESS BELOW

*NOTE: THESE STATEMENTS HAVE NOT BEEN EVALUATED BY THE FOOD AND DRUG ADMINISTRATION. THIS INFORMATION IS NOT INTENDED TO DIAGNOSE, TREAT, CURE OR PREVENT ANY DISEASE.