Health Questionnaire for Custom Supplement Program

Please Complete the Questionnaire Below for a Customized
Supplement Report or Click Here to View our Full Product Line

All information provided is held private and secure. The following questions are intended to provide general indications for your long term nutritional needs and are not intended to diagnose or treat specific medical conditions.

Check the boxes below if you have a recent history on a regular basis of any of the following:

1. Do you find it difficult to eat at least 3 meals a day?
2. Have you ever had a personalized meal plan developed for you?
3. Do you know how many calories you should be consuming to meet or maintain your weight goals?
4. Are you currently taking a daily multiple vitamin?
5. If you take one, do you often MISS taking your Daily Multiple Vitamin?
6. Would you be interested in a comprehensive nutritional solution if it were in a single daily pack?
7. Do you consider yourself "stressed" out often?
8. Do you get heartburn after eating spicy foods, chocolate, citrus, peppers, alcohol, or caffeine?
9. Do you frequently get sick or feel "under the weather" with low energy levels?
10. Do you smoke?
11. Do you ever experience gas, bloating, flatulence, or constipation?
12. Have you ever undergone any type of Detoxification or Cleanse program?
13. Do you experience any type of discomfort in any of your joints?
14. Do you ever experience popping, cracking, or stiffness in your joints?
15. Do you take any anti-flammatory or pain medication for your joints?
16. Do you ever have trouble falling to sleep?
17. Do struggle with maintaining restful sleep and wake up feeling unrefreshed?
18. Do you tend to struggle with weight loss?
19. Do you find it challenging to control your appetite?
20. Do you often have cravings for sugary or other types of foods throughout the day?
21. Are you always on the go and miss meals which may cause low blood sugar & energy levels?