Welcome to nourish! We would love to help you #getnourished!
Below is a short survey to complete which will allow us to suggest the right supplement protocol for you!
Grab a tea, take your time and enjoy!
What is the date today?
Your answer
What medications are you on, if any?
Your answer
What are your weight goals?
Drop 10 pounds or less
Drop 10 pounds or more
Maintain your weight
Gain muscle mass
Other:
What is your age and gender
Your answer
What supplements are you currently taking? If none skip down to the "how do you feel" section
Your answer
I find it hard to take supplements daily
Not at all
1
2
3
4
5
Agree 100%
I find it hard to take my supplements while traveling
Not at all
1
2
3
4
5
Agree 100%
I find it hard to take my supplements more than once a day
Not at all
1
2
3
4
5
Agree 100%
I find it confusing on what to take and when to take it
Not at all
1
2
3
4
5
Agree 100%
How do you feel?
I feel exhausted often
Not at all
1
2
3
4
5
Agree 100%
I get sick often
Not at all
1
2
3
4
5
Agree 100%
My skin is dry and itchy
Not at all
1
2
3
4
5
Agree 100%
My hair is thin and falling out
Not at all
1
2
3
4
5
Agree 100%
My nails are thin and break easily
Not at all
1
2
3
4
5
Agree 100%
I have acne
Not at all
1
2
3
4
5
Agree 100%
I have edema
Not at all
1
2
3
4
5
Agree 100%
I have abdominal pain and bloat after eating
Not at all
1
2
3
4
5
Agree 100%
I have acid reflux and heart burn
Not at all
1
2
3
4
5
Agree 100%
I have painful and irregular bowel movements
Not at all
1
2
3
4
5
Agree 100%
My lips are often cracked
Not at all
1
2
3
4
5
Agree 100%
My tongue is red and swollen
Not at all
1
2
3
4
5
Agree 100%
I have swollen and painful joints
Not at all
1
2
3
4
5
Agree 100%
I get headaches often
Not at all
1
2
3
4
5
Agree 100%
I have poor mental alertness and trouble concentrating
Not at all
1
2
3
4
5
Agree 100%
I have trouble falling asleep or staying asleep
Not at all
1
2
3
4
5
Agree 100%
(Women only)I have irregular, heavy or painful periods
Not at all
1
2
3
4
5
Agree 100%
I have a history of low iron (Ferritin lower than 25)
Yes
No
Not sure
Other:
I have a history of low B12 (blood level lower than 300)
Yes
No
Not sure
Other:
Are you in interested in having children in the next 3 years
Yes
No
Other:
I eat WILD, FATTY fish twice a week and/or take a high quality fish oil supplement
Yes
No
Not sure
Other:
I spend 20-30 minutes in the sun everyday with my arms and legs exposed and/or take at least 1000 IU of Vitamin D /day
Yes
No
Not sure
Other:
I have been on antibiotics, had the flu or had food poisoning in the past year
Yes
No
Other:
How do you currently feel nutritionally
Poor
1
2
3
4
5
6
7
8
9
10
Fantastic
How do you currently feel physically
Poor
1
2
3
4
5
6
7
8
9
10
Fantastic
How do you currently feel mentally
Poor
1
2
3
4
5
6
7
8
9
10
Fantastic
My environment is supportive
Not at all
1
2
3
4
5
6
7
8
9
10
100% supportive
How much are you willing to spend on your supplements for the month?
$50
$100
$200
$300
Other:
How ready and willing are you to take supplements?
Not at all
1
2
3
4
5
6
7
8
9
10
100%
Please leave your name and email address so we can send off your customized supplement regime!
Your answer
Please share any other information you would like us to have.
Your answer
Thank you for your willingness to share and we look forward to working with you! Once you hit SUBMIT your worksheet will be sent directly to the nourish. nutrition team and everything will be kept confidential. We will send you back a copy for your records and contact you with your suggested supplement regime. live fully - keep it simple - #getnourished - the nourish. team
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