Health Challenges Survey

Health Challenge Survey
If there was one thing you could change about your health, what would it be?*
Full Name*
First NameLast Name
E-mail*
example@example.com
Cell Phone Number
Mailing Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Do you currently utilize any of these?*
MultiVitaminOmega III Fish OilB-vitaminsVitamin DProtein ShakesUnder-sink Water FilterPharmaceutical drugsMassage Therapy, Chinese Medicine, Acupuncture

Please check all appropriate boxes

	You	Friend	Family
Asthma / Bronchitis	1	2	3
Allergies / Hay Fever	4	5	6
Allergic Reactions	7	8	9
Migraines	10	11	12
Diabetes	13	14	15
High Blood Pressure	16	17	18
Psoriasis	19	20	21
Damaged Artery Lining	22	23	24
Joint Flexibility	25	26	27
Arthritis Inflammation / Pain	28	29	30

Please check all appropriate boxes

	You	Friend	Family
Ulcers	31	32	33
Gout	34	35	36
High Insulin Needs	37	38	39
Diabetic Retinopathy	40	41	42
Macular Degeneration	43	44	45
Cataracts / Glaucoma	46	47	48
Vascular Disease	49	50	51
Weak Arteries / Veins	52	53	54
Good Cellular Collagen / Elasticity	55	56	57
Poor Lower Leg Blood Volume	58	59	60

Please check all appropriate boxes

	You	Friend	Family
Respiratory Inflammation	61	62	63
Frequent Infections / Flu / Colds	64	65	66
High Histamine Levels / Sinus Problems	67	68	69
Low Energy / Fatigue	70	71	72
Chronic Fatigue	73	74	75
Lupus	76	77	78
Immune Deficiency	79	80	81
Hepatits C	82	83	84
High Cholesterol	85	86	87
Poor Capillaries	88	89	90
Crohn's Disease	91	92	93
Constipation	94	95	96

Please check all appropriate boxes

Please check all appropriate boxes

Please check all appropriate boxes

	You	Friend	Family
Carpal Tunnel Pain	160	161	162
ALS	163	164	165
ADD / ADHD	166	167	168
Fibromyalgia	169	170	171
MS	172	173	174
Hemorrhoids / Prostate Problems	175	176	177
Menopause / PMS / Cramps	178	179	180
Aging Concerns	181	182	183
Cancer Risk	184	185	186

Is there any reason you would NOT be willing to utilize a complementary and/or alternative therapy/solution that would address these concerns?*
No, there is no reason I would not try something...Yes, there is a reason I would not be willing...I am currently under the care of a physician for the above health challenges but would like to integrate alternative evidence-based solutionsOther
Given the boxes you checked, who do you know with any of these health concerns?
Name Relationship Cell Phone Email Address
Referral 01
Referral 02
Referral 03
Should be Empty:

Health Challenge Survey