DISCLAIMER: *

The Taylored Energy Questionnaire is a questionnaire that evaluates the various energy systems of the body. Most specifically – The Immune System, The Endocrine System, The Digestive System and the Circulatory System. The questionnaire is designed to functional as solely an evaluation to give you a detailed, objective-snapshot of your daily energy levels for the purposes of health educational awareness only. It is not for the purpose of medical or chiropractic diagnostic nor does it every constitute as medical or chiropractic diagnostics or treatment of any kind. Consult your primary care physician for diagnostics and treatment advice. Sign Here:

First Name

Last Name

Name *

First Name

Last Name

Birthday *

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Phone *

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Do you have excellent mental focus? *

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10

Is your daily mood level high? *

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10

Do you have consistent uninterrupted nightly sleep? *

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10

Do you have the ability to take full/deep breaths? *

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10

Do you have a strong ability to recover from minor colds/flus? *

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10

Do you experience regular daily bowel movements? *

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10

Do you have consistently high daily appetite levels? *

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10

Do you have motivation to exercise and move regularly? *

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10

Are you living a pain-free life? *

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10

Do you handle daily life-stressors well? *

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10