Health Challenge Survey
If there was one thing you could change about your health, what would it be?
*
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Cell Phone Number
Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you currently utilize any of these?
*
MultiVitamin
Omega III Fish Oil
B-vitamins
Vitamin D
Protein Shakes
Under-sink Water Filter
Pharmaceutical drugs
Massage Therapy, Chinese Medicine, Acupuncture
Please check all appropriate boxes
Rows
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
Rows
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
Rows
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
Rows
You
Friend
Family
Fat Formation / Cellulite
97
98
99
Varicose Veins
100
101
102
Phlebitis
103
104
105
Rough Skin
106
107
108
Bruising / Cracking Skin
109
110
111
Eczema
112
113
114
Sports Injuries
115
116
117
Muscle Cramps
118
119
120
Parkinson's
121
122
123
Vertigo (Dizziness)
124
125
126
Headache Pain
127
128
129
Poor Circulation
130
131
132
Please check all appropriate boxes
Rows
You
Friend
Family
Spasms
133
134
135
Alzheimer's
136
137
138
Environmental Concerns
139
140
141
Wrinkling of the Skin
142
143
144
Pollution
145
146
147
Drugs
148
149
150
Alcohol
151
152
153
Smoke
154
155
156
All Free Radical Damage
157
158
159
Please check all appropriate boxes
Rows
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 solutions
Other
Given the boxes you checked, who do you know with any of these health concerns?
Rows
Name
Relationship
Cell Phone
Email Address
Referral 01
Referral 02
Referral 03
Submit
Should be Empty: