Full Name *

Today's Date

Current Weight

Current A1C

How many medications are you on?

This Wellness Systems Survey is broken down into 5 sections and a portion at the end for your general updates, please choose how often you experience each of the elements. Thank you!

Digestive System Survey:

Gas

Bloating

Constipation

Diarrhea

Incomplete Bowel Movements

Stomach Pain

Excess Hunger

Weight Gain

Sugar Cravings

Vomiting

Cardiovascular System Survey:

Dizziness

Numbness in hands / feet

Coldness in hands / feet

Burning in hands / feet

Thin, Brittle Skin in hands / feet

Tiredness

Cramping / Muscle Fatigue

Pale / Bluish Skin

Sores / Slow Healing

Impotence / Low Sex Drive

Nervous System Survey:

Headaches

Weakness

Daytime Sleepiness

Memory loss

Tremors / Shaking

Sleep Issues

Confusion

Peripheral Neuropathy

Speech Issues

Coordination Issues

Diet Survey:

Vegetables

Lean Meats

Fruits

Fish

Beans / Legumes

Pasta

Rice

Bread

Potatoes

Sweets / Sugar

Lifestyle Survey:

Exercise

64oz of Water (90, 125)

Time outside during the day

Smoking

Drinking

Leisure / Hobbies

Quality Sleep / Well rested

Emotional Issues / Anxiousness

Socialization / Time with friends

Any other updates or Improvements? Please comment below

Thank you!