Health Survey

Please fill out our assessment so we can help you achieve your health goals. We will create your patient profile in our database and a doctor/health consultant will contact you shortly.

Personal Statistics





























Health Assessment

Please state your most significant concerns in order of importance:
Please separate concerns by commas.

Check the conditions that apply to your immediate relatives:







Surgeries: Please check all that apply:









Gastrointestinal Health: Please check all that apply:















Dietary Restrictions: Check which applies best:





Please check off any urinary issue you are currently experiencing:









How much sleep do you usually get per night?





Men: Please check off all that apply




Are you currently taking any medication? Please specify them here.
Please separate medications by commas.

Terms of Service: According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g)(1), the term "Drug" is defined to mean: "Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease." A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy. Although a Vitamin, a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented or be classified as a drug by anyone. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient's diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body. We will make dosage recommendations based on lab results. We have many people that want our advice on medications. It is our intent and policy to give your body the specific nutrients for your body to be as healthy as possible. We will not advise you to get off medications. If you deem appropriate. We will advise with the help of the physician that prescribed them for you. We will not interfere with other physician’s efforts to help you and only ask that they have the respect to not interfere with our efforts to help you become healthy. Clients are advised on dosage required to improve health and lab results. However you are responsible for how you choose to utilize our products. I have read and understand the above.

By submitting this form, I acknowledge that I have read, understand, and agree to these terms of service.