Questionnaire

What's your name?

What’s your email?

We need your email to save your questionnaire results. Make sure you use the email you used for your account sign up

How old are you?

How much do you weigh in pounds?

How tall are you?

How would you describe your approach to health?

Simple and Natural Proactive and Engaged Performance Driven

Where do you live? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Are you..

Male Female

Are you pregnant?

Yes No

Are you nursing?

Yes No

How many hours of restful sleep do you normally get per night?

4-5 5-6 6-7 7-8 8-9 9+

How many hours of restful sleep do you normally get per night?

less than 8 8-10 11 12 13 14+

At what time do you normally go to bed?

9-10pm 10-11pm 11-12am 12am+

How many kids do you have?

0 1 2 3 4 5+

How many kids under 6 do you have?

0 1 2 3 4 5+

Do you enjoy your work most days?

Yes No

How many hours a day are you on a screen, smartphone or wireless device?

0-1 2-4 5-7 8+

On average, how many hours per day do you have to relax?

0-1 1-2 2-3 3-4 5+

On average, do you get 20-30 minutes of sunshine on your body each day between 10AM-3PM?

Yes No

Which best represents your athletic level?

Inactive
Recreational
Intense Recreational or Competitive
Professional

Do you want to lose weight?

No
Yes, 10-20 lbs (5-9 kg)
Yes, 20-40 lbs (9-18 kg)
Yes, 40+ lbs (18+ kg)

Do you want to gain weight?

Yes No

In a normal week, how many hours of each type of exercise do you do?

	Hours per week
Light exercise	0 1 2 3 4 5 6+
Moderate aerobic exercise	0 1 2 3 4 5 6+
Intense aerobic exercise	0 1 2 3 4 5 6+
Moderate resistance or weight training	0 1 2 3 4 5 6+
Intense resistance or weight training	0 1 2 3 4 5 6+

Total number of times you stretch 10+ minutes per week

0-3 3-4 5-6 7+

Which of these describe you?

Choose all that apply

I rarely warm up or stretch before during or after exercise
I use easy initial exercise activity to warm up
I warm up well before stretching & exercise
I stretch before running or exercise
I stretch after exercise

Have you been taking Honed's supplements for the last 3 months or more?

Yes No

Do you follow any of these diets?

Gluten-free Vegetarian Vegan Paleo Ketogenic None

I usually eat organic...

	Mostly / Sometimes / No
Dairy/meat & eggs	M S N
Fruits & vegetables	M S N
Oils (for thing like dressings, cooking or supplements).	M S N

What is the source of most of the water you drink?

City tap Well Plastic (large 10 gallon) bottles Plastic (individual) bottles Bottled glass

Do you prepare most of your meals at home?

Yes No

Do you eat restaurant or frozen meals 2 or more times per day?

Yes No

Do you..

Choose all that apply

Take time to eat in a calm, relaxed way
Chew your food well
Eat breakfast
Eat lunch
Eat dinner
Eat 1-2 snacks per day in addition to meals
Rotate and vary foods
Eat within an hour of waking in the morning
Eat 2-3 hours before going to bed at night
Remain upright for 30-60 minutes after eating a meal
Microwave your food
Heat or microwave your food in plastic

We all need good sleep, how's yours?

Sleep is hugely affected by nutrient levels. We will find out yours.

	Yes / Sometimes / No
Have difficulty falling asleep	Y S N
Wake up in the middle of the night tossing and turning	Y S N
Sleep 8 hours, but don’t feel rested upon waking	Y S N

How's your concentration and energy levels?

Yes, this can be improved by identifying & replenishing missing nutrients.

	Yes / Sometimes / No
Do you crave sweets or carbs	Y S N
Energy swings/dips	Y S N
Do you have trouble concentrating	Y S N
Lethargy in the morning, higher energy at night	Y S N
Lethargy continuous	Y S N
Memory problems	Y S N

What's your mood like?

It's not just you, mood can be hugely impacted by vitamins & minerals.

	Yes / Sometimes / No
Anxiety or panic during the day	Y S N
Anxiety or panic at night	Y S N
Frequently frustrated, agitated or angered	Y S N
Prone to depression or sadness	Y S N

Any aches or pains?

Key minerals like magnesium, and the right oils are frequently involved here.

	Yes / Sometimes / No
Muscle cramping	Y S N
Sore knee(s)	Y S N
Sore hip(s)	Y S N
Sciatica pain	Y S N
Restless legs (usually at night)	Y S N
Tennis elbow or sore forearms	Y S N
Shoulder pain	Y S N
Neck pain	Y S N
Upper back pain	Y S N
Lower back pain	Y S N
Foot pain when walking or running	Y S N
Achilles pain, calf cramps, and/or shin splints	Y S N
Crooked wrists, fingers, or toes	Y S N
Osteoarthritis	Y S N
Disc degeneration	Y S N
Bone spurs	Y N

How's your heart, lung and liver health?

Did you know that congested lungs can mean a tired liver? Our programs will help.

	Yes / Sometimes / No
Irregular heart rhythm	Y S N
Heavy heart beat when lying on left side	Y S N
Shortness of breath	Y S N
Asthma	Y S N
Cold hands or feet	Y S N
Varicose veins	Y S N
Do you have gout?	Y S N
Numbness in face, arms or hands	Y S N
Numbness of neuropathy affecting legs or feet	Y S N
Excess phlegm & mucus	Y S N
Have you had pneumonia in the past?	Y N
Lungs frequently congested	Y S N
Dizziness upon standing	Y S N
Dizziness other	Y S N
Have you had hepatitis or other liver problems	Y N

Any problems with your head or eyes?

Chances are screen time makes your eyes work overtime.

	Yes / Sometimes / No
Headaches (frontal)	Y S N
Headaches (other)	Y S N
Poor night vision	Y S N
Eye strain	Y S N

How's your gut health?

Did you know that fiber and other supplements can help grow healthy gut bacteria?

	Yes / Sometimes / No
Gas or bloating	Y S N
Abdominal cramping	Y S N
Stomach pain or ulcer	Y S N
Heartburn	Y S N
Hemorrhoids	Y S N
1 bowel movement or less per day	Y S N
Constipation	Y S N
Frequent diarrhea	Y S N

What is your typical stool consistency?

Too Hard Medium Too Soft

What is your typical stool color?

Very dark Brown Light

Do you have any bladder or urinary tract health issues?

Minerals like magnesium and specific vitamins can reduce trips to the bathroom at night. They just needs to be in the right form.

	Yes / Sometimes / No
Frequent bladder infections	Y S N
Frequent urination during the day	Y S N
Frequent urination at night	Y S N
Prostate infections	Y S N
Reduced urine flow	Y S N
Enlarged prostate	Y N

Do you experience any of these?

Exercise can really here, but minerals, vitamins and other nutrition can also help relieve these symptoms.

	Yes / Sometimes / No
PMS and/or menstrual breast soreness	Y S N
Menstrual cramps	Y S N
Menstrual irregularity	Y S N
Prolonged menstrual flow	Y S N
Decreased menstrual flow	Y S N
Pain in armpits or other body parts when menstruating	Y S N
Yeast infections	Y S N

Have you had your Thyroid tested and know level?

Low Normal High I don't know

Tell us about your sexual health.

Sexual health is a good sign of overall health.

	Yes / Sometimes / No
Decreased sex drive	Y S N
Lessened erectile function	Y S N

Have you had your testosterone tested and know level?

Not tested
Low
Normal
High

How are your ears, nose, and mouth?

These pesky symptoms can usually be improved through supplements and nutrition.

	Yes / Sometimes / No
Frequent colds	Y S N
Frequent nose bleeds	Y S N
Frequent ear infections	Y S N
Bad breath	Y S N
Bleeding gums	Y S N
Frequent cankers	Y S N
Frequent cold sores or herpes outbreaks	Y S N
Metallic taste on tongue	Y S N

How's your skin?

Skin problems, like warts for example, have been linked to an imbalance between Zinc & Copper. Our analysis will pick it up.

	Yes / Sometimes / No
Warts	Y S N
Frequent shingles	Y S N
Dry skin	Y S N
Oily skin	Y S N
Blemishes or acne	Y S N
Skin rashes	Y S N
Psoriasis	Y S N
Eczema	Y S N
Depigmentation (loss of natural skin color)	Y N
Age spots	Y S N

What about your hair and nails?

Sometimes if your Calcium is too high compared to other minerals, it can make your nails brittle.

	Yes / Sometimes / No
Dandruff	Y S N
Occasional hair loss	Y S N
Male pattern baldness	Y N
Brittle hair	Y S N
Brittle nails	Y S N
Ridges in fingernails	Y S N
White spots in fingernails	Y S N
Nail fungus or athlete's foot	Y S N

Do you have any allergies?

These can be helped by getting your zinc to copper more balanced. We'll let you know if you fall into this group! Exercise can really help here, but minerals, vitamins and other nutrition can also help relieve these symptoms.

	Yes / Sometimes / No
Seasonal or hay fever	Y S N
Dairy, wheat, nuts or shellfish	Y S N

How often do you eat these types of oils?

Think of the number of times you use them in cooking, dressings or on their own.

Olive oil	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Coconut oil	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Flax oil	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Sun of safflower oil	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Pumpkin seed or hemp oil	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Cod liver or other fish oil	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Krill oil	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Vegetable oils (i.e. soybean, corn, canola, peanut, sesame, mazola...)	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Mayonnaise	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Butter	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Cream or whipping cream	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Margarine	2-3 / day 1 / day 1-3 / week 1-3 / month Never

How often do you eat these meats, fish or seafood?

Hot dogs	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Non-organic luncheon meats/cold cuts	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Non-organic red meat	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Predator fish (i.e. tuna, swordfish or halibut...)	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Crustaceans (i.e. shrimp, lobster, crab, oysters...)	2-3 / day 1 / day 1-3 / week 1-3 / month Never

How often do you eat these fried foods?

Fast food	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Frozen dinners	2-3 / day 1 / day 1-3 / week 1-3 / month Never
French fries	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Other deep fried foods	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Potato chips	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Corn or tortilla chips	2-3 / day 1 / day 1-3 / week 1-3 / month Never

How often do you eat these sweets?

Fruit	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Fruit juice	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Fruit yogurt	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Table sugar (teaspoons)	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Ketchup	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Ice cream	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Cookies, muffins or granola bars	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Doughnuts	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Chocolate (organic 85%+ cocoa)	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Chocolate (organic)	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Chocolate (regular)	2-3 / day 1 / day 1-3 / week 1-3 / month Never

How often do you eat these carbohydrates?

Packaged breakfast cereals	2-3 / day 1 / day 1-3 / week 1-3 / month Never
Pasta or bread	2-3 / day 1 / day 1-3 / week 1-3 / month Never

Do you take magnesium?

Yes No

How much salt do you have per day?

Iodized salt (tends to be plain old salt shaker salt and at restaurants)	0-0.5 tsp / day 0.5-1 tsp / day 1+ tsp / day Never
Non-iodized salt (tends to be more granular sea salts)	0-0.5 tsp / day 0.5-1 tsp / day 1+ tsp / day Never

Water (glasses)

1-3 / day 4-6 / day 6-8 / day 8+ / day Never

Other sources

Coffee	2-3 / day 1 / day 1-3 / week 1 / month Never
Caffeinated tea	2-3 / day 1 / day 1-3 / week 1 / month Never
Energy drinks	2-3 / day 1 / day 1-3 / week 1 / month Never
Sport drinks & other	2-3 / day 1 / day 1-3 / week 1 / month Never

How many times per week do you drink alcohol?

1-2 / week 3-4 / week 5+ / week Never

In an average sitting, how many alcoholic drinks would you have?

1-2 3-4 5+

Are you sensitive to vitamins or herbs?

Yes No

Has taking B vitamins ever kept you up at night?

Yes Sometimes No

Are you taking thyroid medication?

Yes No

Have you been diagnosed with Hashimoto's?

Yes No

Do you have low ferritin?

Yes No I don't know

Are you taking a prescription blood thinner?

Yes No

Do have significant difficulty swallowing pills?

Yes No

Do you know your blood pressure?

Yes No

What's your blood pressure?

Have you had oral antibiotics within the last 10 years?

Yes No

Did you avoid sugars and take probiotics after each oral antibiotic prescription for a couple of weeks?

Yes No

Do you have high cholesterol (LDL)?

Yes No

Are you on a statin prescription for cholesterol?

Yes No

Are you on blood pressure medication?

Yes No

Are you using a potassium-sparing diuretic?

Yes No

Are you on an antidepressant?

Yes No

Is the antidepressant that you use one of the following MAOIs? Y/N

Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline (Emsam)
Tranylcypromine (Parnate)

Y N

Are you diabetic and taking insulin?

Yes No

Have you even been diagnosed with cancer?

Yes No

Do you smoke cigarettes?

Yes No