Leo’s Analysis

Risk Factors Survey

How strong is your immunity? Find out how at-risk you are and what you need to do to meet your fitness and vitality goals.

Get on your best path for your most optimal health and fitness.
Bulletproof your immune system.
Immediately develop your desired habits and lifestyle rituals.

Fill out this survey as carefully and completely as possible. We will reply back within 48 hours with your system.

First Name *

Last Name *

Email *

Height *

Weight *

Age *

What if your resting heart rate? *

Check before you go to bed.

How many times per year do you get sick? *

Explain with detail.

How many headaches do you have per week? *

Rate them from 1-10 for severity, 1 being the least severe.

Do you consider yourself an optimistic or pessimistic person? Why? *

What is your most recent blood pressure reading, both the top and bottom numbers? *

What is your total cholesterol number? *

What is your good cholesterol (HDL)? *

What is your bad cholesterol (LDL)? *

Does your normal anxiety negatively interfere with daily functioning? *

Do you live alone? *

How many times per week do you exercise? *

What kind of exercise do you do? Resistant or no resistance? *

Generally, how is your energy level? *

Rate from 1-10, 10 being the highest.

Do you consider yourself a leader? *

Explain why.

Do you consider yourself a follower? *

Explain why.

Do you eat more fast food or home cooked meals? *

Do you have any underlying health conditions, including and not limited to asthma, diabetes, high blood pressure, lung disease, congestive heart failure, heart disease, strokes? *

Please explain.

What kind of medication are you taking? *

What kind of supplements are you taking? *

Do you have circulation issues? *

How often do you get your full panel lipid blood work done? *

How many hours a night do you sleep? *

Are you chronically stressed out? *

Explain with detail.

Are you excited about life? *

Are you diabetic? If yes, Type 1 or 2? *

Are you experiencing menopause? *

If question does not apply, put N/A.

When was the last time you had a period? *

If question does not apply, put N/A.

How if your libido? *

Low, average, high

Do you have skin conditions? *

Please explain.

Do you have problems with constipation? *

Do you have issues with bloating? How often? *

Do you have issues with dehydration? *

Please explain.

Please list any additional information you think that has a positive or negative impact on your life. *

Please explain why.

Give me an example of what you eat in a day during the week and be as detailed as possible about the amount, including drinks. *

Example: 4oz, a cup, a bowl, 2 pieces, 1 serving, etc.

Give me an example of what you eat in a day during the weekend and be as detailed as possible with the amount, including drinks. *

Example: 4oz, a cup, a bowl, 2 pieces, 1 serving, etc.

Leo’s Analysis

Risk Factors Survey

Leo Costa Jr.

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