![mcheader](https://s10900.pcdn.co/wp-content/uploads/2016/05/mcheader-1.png)
![01-age 01-age](https://s10900.pcdn.co/wp-content/uploads/2016/05/01-age-150x150.png)
What is your age?
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![02-gender 02-gender](https://s10900.pcdn.co/wp-content/uploads/2016/05/02-gender-150x150.png)
What is your gender?
![03-weight-height 03-weight-height](https://s10900.pcdn.co/wp-content/uploads/2016/05/03-weight-height-150x150.png)
What is your weight and height?
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![05-energy-level 05-energy-level](https://s10900.pcdn.co/wp-content/uploads/2016/05/05-energy-level-150x150.png)
How is your energy level on a normal day?
![06-stress 06-stress](https://s10900.pcdn.co/wp-content/uploads/2016/05/06-stress-150x150.png)
How often do you get stressed?
![07-sleep 07-sleep](https://s10900.pcdn.co/wp-content/uploads/2016/05/07-sleep-150x150.png)
How do you sleep?
![08-memory-concentration 08-memory-concentration](https://s10900.pcdn.co/wp-content/uploads/2016/05/08-memory-concentration-150x150.png)
How is your memory and concentration?
![09-exercize-week 09-exercize-week](https://s10900.pcdn.co/wp-content/uploads/2016/05/09-exercize-week-150x150.png)
How often do you
exercise each week?
![10-exercize-describe 10-exercize-describe](https://s10900.pcdn.co/wp-content/uploads/2016/05/10-exercize-describe-150x150.png)
How would you describe
your weekly exercise?
![11-cleaning-products 11-cleaning-products](https://s10900.pcdn.co/wp-content/uploads/2016/05/11-cleaning-products-150x150.png)
Do any of your cleaning products
contain bleach or ammonia?
![12-fruit 12-fruit](https://s10900.pcdn.co/wp-content/uploads/2016/05/12-fruit-150x150.png)
How many times per week
do you eat fruit?
![13b-vegies 13b-vegies](https://s10900.pcdn.co/wp-content/uploads/2016/05/13b-vegies-150x150.png)
How many times per week
do you eat vegetables?
![14-grains 14-grains](https://s10900.pcdn.co/wp-content/uploads/2016/05/14-grains-150x150.png)
How many times per week
do you eat whole grains?
![15-dairy 15-dairy](https://s10900.pcdn.co/wp-content/uploads/2016/05/15-dairy-150x150.png)
How many times per week
do you eat dairy?
![16-fish 16-fish](https://s10900.pcdn.co/wp-content/uploads/2016/05/16-fish-150x150.png)
How many times per week do you eat omega-3-rich fish, such as salmon?
![17-water 17-water](https://s10900.pcdn.co/wp-content/uploads/2016/05/17-water-150x150.png)
How many 8-ounce glasses of water do you drink each day?
![18-sugary-drinks 18-sugary-drinks](https://s10900.pcdn.co/wp-content/uploads/2016/05/18-sugary-drinks-150x150.png)
How many times per week do you consume sugary drinks (ex: soda, juices, etc.)?
![19-fast-food 19-fast-food](https://s10900.pcdn.co/wp-content/uploads/2016/05/19-fast-food-150x150.png)
How many times per week do you eat unhealthy snacks or fast food?
![20-breakfast 20-breakfast](https://s10900.pcdn.co/wp-content/uploads/2016/05/20-breakfast-150x150.png)
What do you typically
eat for breakfast?
![21-organic2 21-organic2](https://s10900.pcdn.co/wp-content/uploads/2016/05/21-organic2-150x150.png)
Do you purchase
organic foods?
![dietary-restrictions-1b dietary-restrictions-1b](https://s10900.pcdn.co/wp-content/uploads/2016/05/dietary-restrictions-1b-150x150.png)
Do you have any dietary restrictions?
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![04-select-any 04-select-any](https://s10900.pcdn.co/wp-content/uploads/2016/05/04-select-any-150x150.png)
Please select which of the following apply to you
![23-top3-goals 23-top3-goals](https://s10900.pcdn.co/wp-content/uploads/2016/05/23-top3-goals-150x150.png)
Please identify your top 3 health goals.
[fc id=’7′ align=’center’][/fc]
![24-spend 24-spend](https://s10900.pcdn.co/wp-content/uploads/2016/05/24-spend-150x150.png)
How much would you spend each day
to achieve your optimum health?
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[fc id=’11’][/fc]
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