10X Wellness Assessment
Let's Get to Know Eachother!
First Name
Last Name
Email
Text Number
Country of Residence
Please select...
United States
Other
Question 1
Is your current state of wellness something that
positively impacts your ability to live the life you want
?
Not at all
Sort of
Very much so
Question 2
Have you
taken steps to address or improve
this challenge? How effective have these steps been?
Not at all
Sort Of
Very much so
Question 3
Has your level of wellness made it
easier to enjoy aspects of your life
such as your relationships, work, family, hobbies, or overall ability to do things
at the desired level
?
Not at all
Sort Of
Very much so
Let's Establish a Baseline:
Energy:
How sustainable is your energy on a typical day?
Not at all
Sort Of
Very much so
Libido:
How would you rate your sex drive and any difficulties in performing or staying aroused?
Very Poor
Just Okay
Excellent
Blood Pressure:
Have you been diagnosed with high blood pressure?
Yes
Maybe
No
Thyroid Issues:
Have you been diagnosed with any thyroid conditions, such as hypothyroidism or hyperthyroidism?
Yes
Maybe
No
Mood
:
Do you notice significant mood fluctuations, irritability, or a short temper?
Yes- All the time
Sometimes
No- Never
Brain Fog and Concentration
:
Do you experience periods of brain fog, difficulty concentrating, memory problems, or forgetfulness?
Yes- All the time
Sometimes
No- Never
Gut Issues:
Have you experienced any digestive problems such as abdominal pain, bloating, gas, diarrhea, or constipation?
Yes- All the time
Sometimes
No- Never
Sleep Quality:
How well do you sleep, including difficulties falling asleep, staying asleep, or waking up refreshed?
Very poorly
Just okay
Very well
Weight Management and Body Composition:
Are you satisfied with your current weight and body composition?
Not at all
Sort Of
Very much so
Mental Health:
How often do you experience symptoms of anxiety, depression, constant worries, sadness, or loss of interest in activities?
Very Often
Sometimes
Never
Last few questions...
Have you heard about 10X Health, Gary Brecka, or our medical staff? Please
rate your familiarity with us
on a scale of 1 to 5 (1 being no knowledge about us, and 5 being a 10X Health expert)
1
2
3
4
5
Our approach at 10X Health is different
from others as we focus on comprehensive wellness optimization. We not only aim to address how you currently feel but also dig deeper to understand the underlying causes of your health issues.
Does that resonate with you?
Not at all
Sort of
Very much so