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Family Wellness Assessment
Use this as a tool to assess your health and the health of your family. Once filled the form will get emailed to the address given in this form. The body of the email will contain your answers and you will also receive a PDF copy.
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Email
*
Your email
Date
MM
/
DD
/
YYYY
Name
Your answer
Age
Your answer
Please list names and ages of all family members
Your answer
Describe your overall health and well being.
Your answer
Are there any other specific health issues that you would like us to be aware of?
Your answer
Do you or any of your family members take supplements and / or medications?
Your answer
Have you or someone in your family ever done a cleanse / detox before? If so, when and what did it consist of?
Your answer
Check off all that apply per family member. Please check N/A if family member does not apply.
Allergies to Certain Food
Major Gluten Intolerance
Allergies to Dairy
Allergies to Nuts
Allergies to Certain Grains
Allergies to Plants or Other Greenery
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Allergies to Certain Food
Major Gluten Intolerance
Allergies to Dairy
Allergies to Nuts
Allergies to Certain Grains
Allergies to Plants or Other Greenery
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Check off all that apply per family member. Please check N/A if family member does not apply.
Under Stress
Experience Anxiety
Lack Focus
Other Mental Health Issues
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Under Stress
Experience Anxiety
Lack Focus
Other Mental Health Issues
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
What are your health goals this year? Please check N/A if family member does not apply.
Energy
Weight Loss
Cleansing
Focus
Athletic Performance
Behavior
Better Skin, Hair and Nails
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Energy
Weight Loss
Cleansing
Focus
Athletic Performance
Behavior
Better Skin, Hair and Nails
N/A
Yourself
Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
How is your sleep and that of your family members? Please check N/A if family member does not apply.
Deep Sleep
Moderate
Not Good At All
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Deep Sleep
Moderate
Not Good At All
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you experience any digestion issues? Please check N/A if family member does not apply.
Bloating
Elimination Issues
Indigestion, heart burn, burning stomach acids
Gas pain
None
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Bloating
Elimination Issues
Indigestion, heart burn, burning stomach acids
Gas pain
None
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Are the following items part of you or your family's diet? Please check N/A if family member does not apply.
Meat
Seafood
Dairy
Grains
Gluten
Sugar
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Meat
Seafood
Dairy
Grains
Gluten
Sugar
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Describe your and your family's daily diet.
Your answer
Do you or any family member feel sluggish or yucky throughout the day? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member often get food cravings throughout the day? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Are you or any family member often restless or irritable? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Have you or any family member recently experienced unexplained weight gain or loss? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member often have sore muscles or aches and pains? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member feel unsteady at times and experience dizziness? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member often get headaches? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member have eczema, psoriasis, acne, rashes, or other skin problems? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you have or any family member hormone imbalances / PMS / menstrual problems? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member experience premature aging? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member often have sinus congestion and/or infection? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member find that it is sometimes hard to concentrate? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family members have puffy skin and/or dark circles under the eyes? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Please explain.
Your answer
Do you or any family member have excessive or harsh body odor? Please check N/A if family member does not apply.
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
Yes
No
Sometimes
Not Sure
N/A
Yourself
Your Partner
Child #1
Child #2
Child #3
Child #4
Other Family Member
What are you hoping to gain / change by using Purium superfoods?
*
Your answer
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Once you submit this form you will receive a copy to the email given above. You will see them in the body of the email and in an attached PDF.
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