Dr's Choice Assessment Form
Pro-Active Health Solutions brought to You by the Team at Blueline Products
Referred by? (Who referred You?)
Best Phone Number
International Phone Number
Enter a number greater than or equal to
Solutions(s) that you are most Interested in
Please select your current Work Status that best fits
What type of Work do you do? Occupation
Describe the Stress Level of your Work
Not Applicable (Retired)
Describe the Level of Stress at Home
Check all that apply
Please describe Other Stress if checked above
Diabetics ONLY Section - Skip this section if you do NOT have Diabetes
Use this section only if you have been diagnosed with Diabetes
How long have you had Diabetes? (Years)
What Medications and Dosages do you take for your Diabetes? (List all Please)
What is your Daily Blood Count? (Last 3 days average)
End of Diabetes ONLY Section - Please continue with form
Continue filling out the remainder of the form - Thanks
Please list other Diagnosed Illnesses
Check all that apply to your immediate family (parents, siblings, grandparents)
Check all symptoms you are currently experiencing
Migraines / Headaches
Weak Immune System - Colds and Flu easily
Please list any medications you are currently taking (and dosage if known) :
If you are a woman, are you currently pregnant, or is there a possibility that you are pregnant?
Please describe your alcohol consumption :
Number of Meals on Average Day
Average Time of Last Meal of Day
Daily Food Intake includes (Check All that Apply)
Number of Glasses or Bottles of Pure Water Daily?
Number of #2 Bathroom visits per Day
Any Issues when going to the Bathroom? If Yes, then please describe the best you can.
Number of Hours of Sleep per Day
After Sleeping, Do you fell Rested and Energetic?
ADULTS ONLY: Libido Level
Minutes of Physical Activity per Day
Number of Exercise Days per Week?
Any other Health Concerns that we should talk about?