This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to blood sugar and/or insulin function. It is not a substitute for professional medical advice from your health care provider. Do you have blood sugar (glucose) level issues?*YesNoDo you have insulin concerns?*YesNoDo you have high triglycerides? *YesNoDo you have low HDL ("good") cholesterol?*YesNoDo you have high LDL ("bad") cholesterol?*YesNoDo you have high blood pressure?*YesNoDo you carry excess belly fat? *YesNoAre you overweight?*YesNoAre you physically inactive? *YesNoDo you feel you should eat a healthier diet? *YesNoName* First Last Phone*Email*