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FREE Life Extension Health Profile


We respect your privacy and assure you the information you provide below is for the strict purpose of providing lifestyle guidance. We promise not to sell or use your information for any purpose other than to make recommendation to you. You will receive an email copy of your completed health profile for your use. These recommendations are not intended to replace the advice of your doctor. If you are under a doctors care please consult with him/her before starting this or any other program.
Name:
Address:
City:
State:
Zip/Postal Code:
Home Phone:
Work Phone:
Cell Phone:
Email:
How did you hear about us?:
Sex:
Age:
On a scale of 1-5 with 1 being most important, how serious are you about your health?
Height:
Weight:
Are you satisfied with your current clothing size?
What is your desired size?
How much weight would you like to lose? If you don't need to lose weight please leave blank.
How much weight would you like to gain? If you don't need to gain weight please leave blank.
What have you tried in the past?
Why did or didn't it work for you?
Are you currently taking any medications?
If yes what medications are you taking and why? Leave blank if you are not taking medications.
Do you currently suffer from recurring pain in your body?
What is causing your pain? Leave blank if you do not have reoccurring pain.
Do you have regular headaches?
Do you have allergy problems?
Are you troubled with lack of memory?
Do you have at least one bowel movement per day

Nutrition Category

Do you currently eat at least 3 times a day?
How many times a week do you eat fast foods?
Do you frequently eat restaurants other than fast food?
Do you drink at least 8 glasses of water a day?
Do you regularly drink coffee or caffeine sodas?
Do you regularly drink energy drinks or vitamin waters?
Do you have regular food cravings?
List the foods you crave:

Lifestyle Category

How many times a week do you exercise?
Do you sleep at least 7 hour a night?
Do you smoke?
Do you have a stressful lifestyle?
What supplements or vitamins do you currently take?

Health Risk Factor Category

Does your family have a history of illness such as diabetes, cancer, stroke or cardiovascular disease?
Select the one area that is most important to you
Please confirm your email address so a copy of your personalized recommendations can be sent to you. I understand the recommendations I receive are not intended to replace the advice of a doctor. I agree to hold Life Extension Center, HealthyFix and it's owner, employees, agents and representative harmless as a result of the recommendations and information provided.
 

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