Name *

First Name

Last Name

Phone

(###)

###

####

Within the last 3 months have you followed any of the following diets?

Ketogenic DIet

Intermittent Fasting

Plant-Based

Gluten Free

Dairy Free

Paleo

Whole 30

Weight Watchers

Are you seeking to lose weight? If so, how much?

0-10 lbs

10-20 lbs

20-30 lbs

>30 lbs

I am comfortable in my current weight

Are you currently experiencing any of the following symptoms?

Tired throughout the day

Overall feeling of fatigue

Trouble sleeping

Salt or sugar cravings

Digestive problems

Please select all that apply to your current state of health:

Digestive issues: diarrhea, constipation, delayed gastric emptying, gas/bloating

Immune or autoimmune concerns

Elevated blood pressure and/or elevated blood lipids

Poor sleep or disruptive sleep

Joint pain or osteoarthritis

Allergies including food allergies

Previously diagnosed nutritional deficiencies

Thinning hair, cracked or weak nails, or dry/flaky skin

Eye issues: glaucoma, macular degeneration, other

Sedentary lifestyle

Do you have concerns in any of the following areas of women's health?

Currently pregnant or trying to get pregnant

Poly-cystic ovary syndrome (PCOS)

Peri-menopause or menopause

Severe premenstrual syndrome (PMS)

Frequent urinary tract infections

Do you frequently experience any of the following?

High levels of stress

Generalized anxiety

Sad or depressed mood

How many fruits and vegetables do you eat daily?

0-2

3-5

6 or more

How often do you eat meat or poultry?

0-3 times/week

4-5 times/week

Most days of the week

Several meals daily

How frequently do you eat fish?

0-1 times/week

2-3 times/week

3+ times/week

Please indicate your alcohol consumption:

0-1 days/week

2-3 days/week

More than 4 days/week

How important is it for you to have vitamin and nutrition products that are made from premium ingredients and quality tested?

Very important

Somewhat important

Neutral

Not important at all