Step 1 of 10 10% ENERGY LEVEL*How energized do you feel on a regular basis? I am always tired, even after waking I am tired most of the time I typically get tired later in the day I can make it through half of the day I often experience fatigue at least once a day I feel tired at least a few times a week I get fatigued once or twice a week I get tired occasionally after a hard day I am energized most of the time I am always energized SEXUAL PERFORMANCE*How is your sexual performance? I have complete erectile failure and dysfunction I am having difficulty maintaining an erection I barely have any desire at all for sex I have very little desire these days Sex – I kind of forgot what that is I try to get in the mood once or twice a month Once a week is enough for me I have sex a few times a week I enjoy sex numerous times a week My sex life is as great as it has always been DRIVE AND PRODUCTIVITY*Choose the response below that best fits how driven, focused, and productive you are. No drive, focus, or desire to do anything Very little drive or desire to get work done Reduced drive and focus, poor performance on the job Barely meets deadlines, not focused on goals or tasks Below average work results, decreased drive Happy to just complete tasks, doesn’t look for extra work Tries to get things done, sometimes misses deadlines Usually well-focused, driven, and meets most deadlines Typically focused, motivated, and gets results Very focused, driven, motivated, over-achiever MUSCLE TONE*How does your muscle tone appear now compared to six months or one year ago? I have lost all muscle tone and strength My muscle tone and strength are seriously failing I have stopped exercising due to decreased strength and endurance I am finding it hard to exercise due to muscle loss and decreased strength I no longer have a toned bodily image My muscle size is shrinking no matter how hard I exercise I am finding it hard to maintain toned muscles with my workouts My muscles are toned, but not where they were in the past My muscles are well-developed with very little body fat My body is firm, chiseled, and well-toned MENTAL FUNCTIONS*Think about your level of concentration, memory, performance of cognitive functions, and then find the response below that best fits that image. I am extremely forgetful and cannot do simple math calculations in my head anymore I may joke about it, but my lack of memory is scaring me Lack of focus and memory are starting to interfere with my life It is getting harder to focus or recall things that I should know I forget something at least once a day and find it hard to learn new tasks I forget things on a regular basis and lose focus often My memory, focus, and mental skills are not as sharp as in the past I sometimes forget why I entered a room or where I placed something I rarely lose focus or forget anything My mind is as sharp as it ever was WEIGHT GAIN*Where is your weight at today? Choose the number below that corresponds to where you currently are on the scale. I am more than one hundred pounds overweight I have more than 75 pounds to lose I am more than sixty pounds overweight I have been diagnosed with obesity I need to drop fifty pounds I have thirty to forty pound to lose I am twenty pounds overweight I need to lose ten pounds I could use to lose five pounds I am at my ideal weight MOOD AND DEPRESSION*Are you still the same happy-go-lucky person you were in years past, or do you find yourself fighting off feelings of depression or mood swings? Clinical diagnosis of depression Overall feelings of depression, anxiety, sense of hopelessness Increased mood changes, anxiety, aggression Frequent outbursts, mood swings, increased stress Unhappy with life, concerned about the future, moody Frequent feelings of stress, anxiety, mood changes Mixed feelings for the future, some mood swings Occasional concerns for the future, usually happy Fairly positive outlook, calm, happy mood Positive outlook on life, happy mood, excited SLEEP*Are you getting enough sleep at night and feeling refreshed and invigorated in the morning? I get only a few hours of sleep each night I am always waking up tired from lack of sleep I have a hard time falling asleep and awake frequently during the night I have insomnia that makes it hard to fall asleep most nights I sometimes need a sleeping pill to help me fall asleep I am fine with five hours of sleep each night I average six hours of sleep each night and still awake fairly refreshed I try to get eight hours of sleep each night, but I miss a few nights I typically get eight hours, but not always I wake up refreshed after eight solid hours of sleep each night HAIR LOSS*Do you still have a thick, full head of hair? Has the color turned gray? Extreme baldness and hair loss from body Patches of thinning hair very noticeable, increased balding Increased hair thinning on body and head More hair is noticed in brush or comb Thinning hair is starting to cause emotional distress Increased thinning of hair is apparent Reduced growth of hair on body and head Hair on head is losing its shine and thickness Possible hair thinning and a slight increase of hairs in brush or drain Thick, full head of hair CHOLESTEROL LEVELS*Have you been diagnosed with high cholesterol? Extremely high cholesterol that is not responding to medication Extremely high cholesterol that is responding to medication Prescribing of medication to lower cholesterol levels Extremely high cholesterol that is not responding to dietary changes Possible need for medicine for high LDL levels Warning from doctor to change dietary and exercise habits Borderline high LDL levels Slightly elevated LDL levels Barely elevated LDL levels Perfect cholesterol levels Name* Email* Phone*HiddenSkillsInterests
