Cynthia Blackwell Wellness

New Body. New Life. New You.

(407) 250-9176

How Quickly Is Your Body Aging?

Are you male or female?

Male

Female

Select your age range:

Please choose one*

25-34
35-44
45-54
55-64
65+
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Are you as healthy today as you thought you'd be at this stage of life?

Yes

Are you dealing with any of the following? (Check all that apply)

Brain fog and/or lack of memory function

Lack of energy and/or stamina

Decreased libido and/or sexual function

Hard to lose weight / stubborn body fat

Aches and pains in my bones and/or joints

Trouble with flexibility

Energy and Stamina

Are you dealing with any of the following? (Check all that apply)

I usually wake up feeling groggy / I don't feel rested

I require coffee in the morning to get me going

I usually feel tired after meals

My energy level dips in the afternoon

I don't have the energy level I used to. I get tired quickly if I exert myself.

I have low energy all the time

Sleep Quality

How many hours of sleep do you average per night?

Please choose one*

8+
7-8
6-7
Less than 6
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Do you have trouble sleeping? (Check all that apply)

I have trouble falling asleep at night. (Can't get my brain to shut down enough to relax.)

I have trouble staying asleep. I usually wake up in the middle of the night.

Stress

How would you rate your stress levels?

I have no stress

I encounter stress but have great ways to handle it

I don't like the way I handle stress. Just thinking about stress makes me stressed

Horrible. I'm stressed all the time and it affects every part of my life

Muscle / Recovery

Are you dealing with any of the following? (Check all that apply)

Joint discomfort

I am slow to recover after exercise

I am slow to recover after injuries

Loss of muscle mass / I don't have the physical strength I used to

I don't get the same results I used to from working out

This is a significant issue for me

Physical Appearance

I'm noticing new wrinkles and/or crow's feet around my eyes

Age spots

Hair is graying

Hair is thinning or dull or slow-growing

Skin is dull or wrinkled or sagging

My skin usually feels dry and dehydrated or cracked

I'm aging faster than my friends who are of the same age

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