www.mdah.com/survey.htm

Health Survey

Double-check the data you entered so far,
or please enter it now if you didn't yet.

 

Gender:

     Male   Female

Age:

  

Height:

    ft.   in.

Weight:

    lbs.

Target:

    lbs.

Email:

  
 

Finish filling out the following form and we will send your results to the email you entered.

Lifestyle Information

1. Not counting the time you spend exercising, how would you describe your level of daily activity?
  Sedentary. You spend most of the day seated at a desk or you have a leisurely lifestyle.
  Active. Your job requires some physical exertion or you have an active lifestyle.
  Very Active. You have a physically demanding job or have a very active lifestyle.
2. Smoking:
  Yes
  No
  Occasionally / Socially
3. Drinking
  Yes
  No
  Occasionally / Socially

Medical History

4. Are you at risk for or concerned about any of the following conditions? (check all that apply)
  a. Allergies and/or Asthma
  b. Bladder Conditions
  c. Breast Cancer
  d. Depressio
  e. Diabetes
  f. Heartburn/GERD
  g. Heart Disease
  h. Hypertension (High Blood Pressure)
  i. None
5. List any physical limitations / body ailments:
  

Food Habits / Diet

6. What Diets have you tried in the past (check all that apply)
  Atkins
  Weight Watchers
  The Zone
  Other
  None
7. How many times do you eat a day?(4-8 recommended)
8. Food Habits
  Vegetarian
  Semi-Vegetarian (no meat)
  General
  Fast-Food Junkie
9. Main meal: (largest)
  Breakfast
  Mid-Morning
  Lunch
  Evening Dinner
  Late Night Eating
10. Water Intake (glasses): (6 (8oz) glasses/day recommended)

Exercise Habits and Equipment

11. Do you exercise?
  Yes
  No
  Occasionally
12. If you exercise, what type: (check all that apply)
  Cardiovascular
  Weight Training
  Stretching and Flexing
13. If you exercise, how often?
  Daily
  3x Week
  Once / Week
  Less than once / week
  Less than once / month
14. List your exercise accessories: (check all that apply)
  Free Weights (no bench)
  Free Weights (with bench)
  Weight Machine
  Treadmill
  Rowing Machine
  Skiing Machine
  More? (list below)
  
   Submit

Instructions

Only a few questions left to get your personal fitness profile and diet goals. Tell us a bit about your history and lifestyle so that we can assess your fitness level and come up with a plan that works best for you.

Finish filling out the questions, and click submit at the bottom of the page.

Important Note:

We recommend you print out your Health Form Results (link will be sent via email) and bring it to your personal physician before starting any new diet plan or exercise regiment.

Privacy Assurance:

We at Men's Diet & Health assure you that this data will be kept completely confidential and will be utilized solely towards the personalization of your Diet / Food Plan.