Womens General Health Assessment | Complete Wellness Evaluation

What is your gender?

FEMALE

MALE

What is your date of birth?

Month:

Day:

Year:

What is your height and weight?

Height (ft):

Height (in):

Weight (lbs):

How would you rate your current overall health?

Excellent - I feel great and have no health concerns

Good - I feel generally healthy with minor issues

Fair - I have some health concerns that affect me

Poor - I have significant health issues

Very Poor - I have serious health problems

How are your energy levels throughout the day?

High and consistent throughout the day

Moderate and consistent

High in morning, lower in afternoon

Good in morning, crash in afternoon

Consistently low throughout the day

How many days per week do you engage in moderate to vigorous exercise?

6 or more days

4-5 days

2-3 days

1 day

I rarely or never exercise

How would you describe your typical diet?

Primarily whole foods, rich in fruits and vegetables

Generally balanced with some processed foods

Mixed - some healthy, some processed foods

High in processed foods and sugar

Irregular or often skip meals

How would you rate your mental health and emotional well-being?

Excellent - I feel mentally strong and emotionally stable

Good - Generally positive mood with minor fluctuations

Moderate - Some mood swings but manageable

Poor - Frequent mood issues affecting daily life

Very Poor - Significant mental health struggles

How would you describe your stress levels?

Very Low - I rarely feel stressed

Low - I experience minimal stress

Moderate - I experience some stress but manage it well

High - I frequently feel stressed and overwhelmed

Very High - I feel constantly stressed and struggle to cope

How would you describe your sleep quality?

Excellent - Deep, restorative sleep every night

Good - Generally restful sleep most nights

Moderate - Some sleep issues but mostly restful

Poor - Frequent sleep problems affecting daily life

Very Poor - Severe sleep issues

How would you describe your social connections and relationships?

Excellent - Strong, supportive relationships

Good - Generally positive relationships

Moderate - Some good relationships, some challenges

Poor - Limited or strained relationships

Very Poor - Isolated or toxic relationships

How would you describe your ability to focus and concentrate?

Excellent - No issues with focus or concentration

Good - Minor focus issues, easily managed

Moderate - Some difficulty concentrating at times

Poor - Significant focus problems affecting work/life

Very Poor - Severe concentration issues

How would you describe your overall mood?

Very Positive - Optimistic and happy most of the time

Positive - Generally good mood with occasional lows

Neutral - Stable mood, neither particularly high nor low

Negative - Often feeling down or irritable

Very Negative - Frequently depressed or anxious

How would you describe your motivation and drive?

Very High - Highly motivated and driven

High - Generally motivated with clear goals

Moderate - Some motivation but could be stronger

Low - Often struggle with motivation

Very Low - Frequently lack motivation and drive

How would you describe your overall life satisfaction?

Very Satisfied - I am very happy with my life

Satisfied - I am generally happy with my life

Neutral - I am neither particularly satisfied nor dissatisfied

Dissatisfied - I am often unhappy with my life

Very Dissatisfied - I am very unhappy with my life

Select any symptoms you are currently experiencing:

Chronic fatigue or low energy

Brain fog or mental clarity issues

Anxiety or nervousness

Depression or low mood

Sleep problems or insomnia

Frequent headaches

Joint or muscle pain

Digestive problems

Frequent colds or infections

Slow wound healing

None of the above

Contact Information

Your information is secure and will be used to create your personalized health assessment.

First Name

Last Name

Email Address

Phone Number

We respect your privacy and will never share your information with third parties.

Low T. High Impact.

Health Assessment

What is your gender?

What is your date of birth?

What is your height and weight?

How would you rate your current overall health?

How are your energy levels throughout the day?

How many days per week do you engage in moderate to vigorous exercise?

How would you describe your typical diet?

How would you rate your mental health and emotional well-being?

How would you describe your stress levels?

How would you describe your sleep quality?

How would you describe your social connections and relationships?

How would you describe your ability to focus and concentrate?

How would you describe your overall mood?

How would you describe your motivation and drive?

How would you describe your overall life satisfaction?

Select any symptoms you are currently experiencing:

Contact Information

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