VIVA Life Science | Nutritional Science

Health and Nutrition Questionnaire

The following questionnaire will help our VIVA nutritionists design a personalized supplement program just for you. Take a few minutes now and you can add years to your life and life to your years!

Please fill out this form as accurately as possible. Once you submit the form, a list of products will be e-mailed to you that will be tailored to your specific needs to help you maintain your health or give nutritional support for your health challenges.

DISCLAIMER: The following questions are not intended to diagnose, treat or prevent any disease. Please consult with your physician or healthcare professional for any medical advice, especially if you are pregnant, nursing or have or suspect any illness or condition.


Name:
E-mail:
Age:
Sex:

FOUNDATIONAL-General Health
I am generally healthy, no complaints.	I am a vegetarian.
I usually get 6 to 8 hours of sleep regularly	I drink 8 to 10 glasses of pure water daily.
I take prescription or non-prescription drugs regularly.	I exercise regularly (at least 3 times per week).
I eat plenty of high-fiber fruits, vegetables and grains.	My lifestyle and work are satisfying and I am content.
CARDIOVASCULAR SYSTEM
My pulse is slow and/or strong.	My pulse is rapid and/or light.
I am often cold and dry.	I am often warm and sweaty.
I often feel dizzy or faint.	My blood pressure is often over the normal range.
I have frequent heart palpitations.	My cholesterol or triglyceride levels are above normal range.
IMMUNE SYSTEM
I bounce back from illness quickly.	I have a history of asthma, allergies or hay fever.
I drink alcoholic beverages frequently.	I catch colds and the flu easily.
I often have to take antibiotics.	I get yeast infections easily.
My injuries heal quickly.	I often get earaches or sore throats.

NERVOUS SYSTEM
I think clearly and have a good memory.	I am frequently depressed, moody or cannot sleep.
I cannot get the day started without coffee.	I am often nervous or cry easily.
I get headaches frequently.	My work, home life or lifestyle is very stressful.
RESPIRATORY SYSTEM
I rarely have coughs or breathing trouble.	I often have shortness of breath when standing or walking.
I use tobacco frequently.	I am often exposed to second-hand smoke.
I breathe rapidly and shallowly.	I yawn frequently.
I have a history of asthma, allergies or hay fever.	I am often exposed to pollution or chemicals in my environment.
DIGESTIVE SYSTEM
I rarely experience indigestion or heartburn.	I am often constipated.
I experience diarrhea often.	Sometimes I feel bloated and have stomach or intestinal gas after eating.
I digest my foods easily.	I often have stomachaches or cramping.
METABOLIC SYSTEM
I am energetic all day and sleep well at night.	I am often tired and sluggish by mid-afternoon.
I tend to lose weight easily.	I would like to lose some weight.
I am more than 10 pounds overweight.	Dieting is too hard for me.
I crave sweets.	My blood sugar levels are over the normal range.
MUSCULOSKELETAL SYSTEM
I generally have good posture and strong muscles.	My fingernails break, peel or crack easily.
I often have painful joints or aching muscles.	My bones are easily broken or weakened.
My activities are slowed down because of pain.
GLANDULAR SYSTEM
My skin is smooth and wrinkle-free.	I have acne.
I have age spots on my skin.	My menstrual cycles are irregular or I have PMS.
My hair is dull and breaks easily.	I would like to improve my sexual drive.
HEALTH CONCERNS
Aging	Cardiovascular Health
Cholesterol	Immune System Health
Memory	Mood
Mental Clarity	Sinus/Allergy health
Lung Function	Bowel Function
Digestive Health	Weight Control
Endurance and Strength	Energy
Bone and Joint Function	Hair, Skin and Nails
Reproductive and Female Health	Reproductive and Male Health
Sexual Health

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