Name *

First Name

Last Name

Health Score *

Tired most of the time

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Overweight

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Prone to hormonal symptoms

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Suffering from dark circles or bags under your eyes

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Suffering from poor memory or concentration

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Often feeling anxious or stressed

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Very dry skin in need of daily moisturisers

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Difficulty sleeping

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Low or depressed

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Prone to indigestion or bloating after food

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Energy & Bloody Sugar Control Score *

I often have mood swings or difficult concentrating

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

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

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I often over-react to stress

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I often crave something sweet or coffee after meals

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I have less energy than I used to have

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I often feel too tired to exercise

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am gaining weight and/or finding it harder to lose weight

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I often have energy slumps during the day or after meals

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I still feel tired 20 minutes after getting up

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

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

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

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

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree