Wellness Health Survey

Are any of these areas a concern to you or someone you know?

Address *

Line 1

Line 2

City

State

Zip Code

Country

Energy and or/Healthier Alternative to Energy Drinks *

Yes No

Joint/Ligament Flexibility (Carpet Tunnel, Arthritis, RA, Orthopedic, etc) *

Yes No

Heart Health (Blood Pressure, Cholesterol levels, Vascular, Clotting, Circulation) *

Yes No

Respiratory Health (Asthma, Allergies, Sleep Apnea, etc) *

Yes No

Digestive Health (Acid Reflux, Ulcers, IBS, Crohn's, Colitis, etc) *

Yes No

Improved Sense of Well- Being (Stress, Anxiety, Depression) *

Yes No

Foot/Muscle Relief (Gout, Cramping, Restless Leg) *

Yes No

Healthy Immune Function (Colds, Flu, Autoimmune Diseases) *

Yes No

Skin Health (Eczema, Psoriasis, Acne) *

Yes No

Do you take vitamins or herbals of any kind? *

Yes No

Are you under the supervision of a Health Professional? *

Yes No

Do you take prescription medication? *

Yes No

If you could Improve ONE thing about you health, what is your priority? *

How do you feel about your health today? -5, -4, -3, -2, -1, 0, +1, +2, +3, +4, +5 *

Where would you like your health you be? -5, -4, -3, -2, -1, 0, +1, +2, +3, +4, +5 *

Note: it is our goal to support you by offering you a free online resource for education, science and wellness support.

Please indicate which free wellness classes you wish to be informed of in the future. *

Health Reality Check Why Diets Don't Work Improving your Diegestion Anti-aging

Please take a few minutes to fill out our health survey below! Once we receive your survey we will contact you by email to set up a time to discuss your health survey and solutions for your health needs.