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YOUR FREE HEALTH AND ENERGY ASSESSMENT

Your Assessment Form

How healthy and energetic do you feel?

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Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9

Step 1

Health Assessment

Tired most of the time

1

2

3

4

5

Disagree........................Agree

Overweight

1

2

3

4

5

Disagree........................Agree

Prone to hormonal symptoms

1

2

3

4

5

Disagree........................Agree

Suffering from poor memory and concentration

1

2

3

4

5

Disagree........................Agree

Step 2

Low or depressed

1

2

3

4

5

Disagree........................Agree

Plagued by dry skin in need of daily moisturisers

1

2

3

4

5

Disagree........................Agree

Having difficulty sleeping

1

2

3

4

5

Disagree........................Agree

Often feeling anxious or stressed

1

2

3

4

5

Disagree........................Agree

Step 3

Prone to indigestion or bloating after food

1

2

3

4

5

Disagree........................Agree

Often constipated (you rarely go twice a day)

1

2

3

4

5

Disagree........................Agree

Suffering from dark circles or bags under your eyes

1

2

3

4

5

Disagree........................Agree

Step 4

Total Score:

Ideal target: 14 or less

Step 5

Energy & Blood Sugar Control:

I still feel tired 20 minutes after getting up

1

2

3

4

5

Disagree........................Agree

I often crave chocolate, sweet foods, bread, cereal or pasta

1

2

3

4

5

Disagree........................Agree

I need tea, coffee or a cigarette, or something sweet to get me going in the morning

1

2

3

4

5

Disagree........................Agree

I often have energy slumps during the day or after meals

1

2

3

4

5

Disagree........................Agree

Step 6

I often crave something sweet/coffee after meals

1

2

3

4

5

Disagree........................Agree

I often have mood swings or difficulty concentrating

1

2

3

4

5

Disagree........................Agree

I get up dizzy or irritable if I go 4 to 6 hours without food

1

2

3

4

5

Disagree........................Agree

I often overreact to stress

1

2

3

4

5

Disagree........................Agree

Step 7

I have less energy than I used to

1

2

3

4

5

Disagree........................Agree

I often feel too tired to exercise

1

2

3

4

5

Disagree........................Agree

I am gaining weight / finding it harder to lose weight

1

2

3

4

5

Disagree........................Agree

Step 8

Total Score:

Ideal target: 16 or less

Step 9

Please fill in your details below

First Name

Surname

Email

Contact Number

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if your score is for over 26 on either scale, there is room for serious improvement!

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