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Fact: Millions of people don't know they are at risk for many common diseases and that simple lifestyle changes could reduce, or even eliminate those risks.

Don't be one of those people.

This easy online form will not take you much time. Most people can complete it in under 5 minutes.

When you complete the survey you will be emailed a report that will detail your possible health risks and simple ways you may be able to reduce or eliminate them.

Don't wait. Take the Simple Health Survey now.

Instructions: The Simple Health Survey is easy to take. Just complete the following questions and you will receive your report instantly.

Note:  * indicates a required answer.

Please answer the following questions about yourself.

1. What year were you born?  *   

2. Your gender  *

3. Your weight in pounds?  *   

4. What is your height?  *   

5. Do you have allergies?  *

6. Do you have joint pain, arthritis or inflammation?  *

7. Have you ever had cancer?  *

8. Do you have trouble remembering information?  *

9. Do you have high blood pressure or are you taking blood pressure medication?  *

10. Are you a smoker?  *

11. Do you have high cholesterol or are you taking cholesterol lowering medication?  *

12. Do you have diabetes?  *

13. How would you describe your vision?  *

14. Have you had any heart attacks or strokes?  *

15. How would you describe your level of stress?  *

16. How would you describe your level of activity?  *

17. How many hours do you sleep on average per night?  *

18. How many servings of fruit and vegetables do you eat each day?
Examples: 1 serving = Fruit (1/2 banana, 1 small apple, orange or pear, 1/2 cup chopped, cooked or canned). Vegetables (1 cup leafy or 1/2 cup cooked, raw, canned or juiced).

19. How many glasses (8 ounces) of pure water do you drink each day?  *   

20. Do you eat red meat, fast food, fried food or pre-packaged food more than 3 times per week?  *

21. Do you eat fish 3 or more times a week or take fish oil supplements?  *

22. Do you tend to hold onto unforgiveness, bitterness or anger?  *

23. Do you feel you are a thankful or grateful sort of person?  *

24. Do you feel you give and receive love in your life?  *

First Name: * 
Last Name: * 
Email Address: *

Please Note:
Your Simple Health Survey report will be sent to the email address you entered above. If you have entered an invalid email address, you will not receive your report. If you do not get your email please look in your spam or junk folder.

Privacy: We never share your information with any third parties.

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