Assessment

Assessment Form

CarePro Advance Health is committed to promoting good health. Building a good nutritional foundation is critical to health and healing. Dietary Guidelines for Americans 2010 found that 75-95% of Americans do not get the minimum servings of fruits and vegetables, leaving them deficient in some nutrients. The American Medical Association agrees that we cannot get everything we need from our diet.
Let our clinical pharmacist make a recommendation for a good nutritional supplement foundation that is just right for you or your family member. Completing the questions on this assessment will help us make a recommendation that is well-suited to each person’s individual needs. Feel free to take the assessment for your child, yourself or your spouse. Take it as many times as you would like. We want you and your family to be happy….and healthy!

Your Name (required)

Your Email (required)

Age(required)

Weight (Required)

Gender (Required)
 M F

Is your second toe longer than your big toe (Morton’s toe)?

 Yes No

Do you suffer from food sensitivities?

 Yes No

Are you fructose intolerant?

 Yes No

Do you have trouble swallowing pills?

 Yes No

Does the smell of multivitamin tablets or capsules bother you?

 Yes No

Have you experienced stomach upset when taking a multivitamin?

 Yes No

Have you had bariatric surgery, have an ostomy, or suffer from a disorder that decreases your ability to absorb nutrients?

 Yes No

Do you suffer from chronic fatigue or a disorder that affects your energy level?

 Yes No

Do you suffer from metabolic syndrome? For a diagnosis of metabolic syndrome you would need to meet at least 3 of the following criteria:
 Yes No
  • Central obesity: waist circumference >/= 40 inches (male) or 36 inches (female)
  • Dyslipidemia: triglycerides >/= 150 mg/dl
  • Dyslipidemia: HDL < 40 mg/dl (male) or < 50 mg/dl (female)
  • Blood pressure >/= 130-85
  • Fasting blood glucose >/= 110 mg/dl

Are you pregnant or planning to become pregnant?

 Yes No

Have you had a problem in the past with fish burps after taking a fish oil supplement?

 Yes No

Are you vegetarian, vegan or allergic to fish?

 Yes No

Do you have ADHD, ADD, autism or had a brain injury?

 Yes No

Is your immune system compromised due to disease, or are you taking medications after an organ transplant, are currently receiving chemotherapy, or have had part of your gut removed so that you now have short gut?

 Yes No

We will respond to your online assessment within 72 hours of submission with an email and a list of products that are well suited to you or your family member.
Feel free to contact us at info@careprohs.com if you have further questions.