Peak Performance Wellness Center
Lifestyle Assessment Form
 
 If a question does not pertain to your reason for scheduling an appointment, enter "NA" for your response


What kind of water do you drink? * *
Do you take Probiotics? *
Do you take Digestive Enzymes? *
Which meals do you eat each day? *
 
What type of foods do you crave?
 Check all that apply
Sweet
Salty
Chocolate
Bread
Do you smoke? *
Which of these do you consume?
 Select all that apply
Coffee
Soda Pop
Milk
Sweet Tea
Energy Drinks
Juice
Herbal Tea
None of the Above
Do you have a pacemaker or other electronic implanted device? *
Details for Your Appointment
To prepare for the scan that will take place during your appointment, please follow these guidelines:
Drink 8 ounces of water throughout the hour before your appointment.
No alcohol 12 hours before your appointment.