Do you experience headaches?
Do you suffer from colds or the flu?
Do you ever have stomach problems or heartburn?
Do you suffer from arthritis or diabetes?
Do you suffer from high blood pressure or high cholesterol?
Do you have any skin problems, pimples, acne, etc?
Are you overweight?
Do you take any drugs (include prescription or other)?
Do you suffer from constipation problems?
Do you suffer from depression?
Do you experience body odor?
Do you wake up groggy or experience lack of energy throughout your day?
Have you been to a medical doctor for an illness during the past year?
Have you lost any time from work due to illness during the past year?
Do you experience interruption in your sleep throughout the night?
Do you eat meat or poultry products?
Do you consume milk, cheese or other dairy products?
Do you consume products containing refined sugar?
Do you eat foods containing white flour or table salt?
Do you consume products containing caffeine?

Please complete the following required information:

First Name: Last Name:

Street Address:

City: State Zip


Phone: (optional)

How did you hear about the PerforMax Health Assessment?