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About us
Lifestyle Survey
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Lifestyle Assessment

Congratulations on taking the first step toward a healthier lifestyle! Complete the questionnaire below and receive your instant Personal Wellness Snapshot — a free, private mini-assessment scored right on this page.

APersonal Information

First Name

Last Name

Mailing Address

Date of Birth

Age

Gender

Male Female

Height (ft/in or cm)

Weight (lbs or kg)

Daytime Phone

Evening Phone

BMy Lifestyle & Fitness Goals

Healthy weight loss Improve overall health Improve flexibility Healthy weight gain Prevention of disease Address medical conditions Increase physical activity Increase strength Other Make better food choices Increase physical endurance

Target Weight

Target Date for Attaining Weight Goal

CMedical History

Do you currently experience the following symptoms or have been diagnosed with any of these medical conditions? Check all that apply.

Allergies Digestive Health (IBS, Crohn's) Joint Pain Anxiety and Stress Osteoporosis, Osteoarthritis Heart Disease Asthma Low Back Pain High Cholesterol Depression Neck Pain Migraine, Headaches Diabetes Type 1 Chronic Muscle Soreness Other, specify Diabetes Type 2 Injuries

If “Other” — please specify

Are you pregnant?

No Yes

If yes, anticipated due date

Do you currently smoke?

No Yes

If yes, cigarettes/cigars per day & for how long

Have you ever smoked?

No Yes

Does anyone else smoke in your household?

No Yes

Your workplace?

Yes No

Family history / hereditary diseases

Health of relatives (Father / Mother / Siblings)

Have you ever been hospitalized?

No Yes

If yes, what was the reason?

DDaily Lifestyle Check

Answer these 10 quick questions honestly — they generate your instant Wellness Snapshot. 1 = rarely / poor · 5 = almost always / excellent.

I confirm that the information provided above is accurate to the best of my knowledge, and I consent to Heavenly NHH Virtual collecting this information in accordance with applicable privacy regulations.

On submit, your assessment is shared securely with Dr. Gel — and your personal Wellness Snapshot appears instantly.

Heavenly Natural Holistic Healing

Your Personal Wellness Snapshot

Prepared for you

Overall Wellness

Recommended next steps from Dr. Gel

This Wellness Snapshot is an educational self-assessment based on your own answers. It is not a medical diagnosis and does not replace professional care. For a full evaluation, book a consultation with Dr. Gel Clerjuste.

Wellness Concierge

Heavenly Natural Holistic Healing

“

Experience whole-person healing from the comfort of home — Heavenly Natural Holistic Healing brings you compassionate, expert virtual care that nurtures your mind, body, and spirit as one.

Heavenly Natural
Holistic Healing

Virtual Integrative Care

Florida, United States 89704

+1 (954) 394-3741

info@heavenlynhhvirtual.com

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