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Health Advisor Questionnaire
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* Indicates required question
First Name
*
Type your name
Your answer
Last Name
*
Your answer
Email Address
*
Type your email address
Your answer
GENERAL Questions
How old are you?
*
Prefer not to answer
<30
30-39
40-49
50-59
60+
What is your level of education?
*
Prefer not to answer
Did not finish high school
High school
College or University
Masters or Doctor or PhD/Post Graduate Studies
What are your top 3 health concerns?
*
Weight
Anti-Aging & Hormones
Energy
Stress
Digestion
Pain
High Blood Pressure or Cholesterol
Optimize Health
Required
What country do you live in?
*
Canada
Northern US
Southern US
What are the current supplements that you take on a regular basis i.e. at least 5 times a week?
*
I do not take any supplements
Multivitamin
Fish oil
Greens
Probiotics
One of the following: Vitamin A-C-E; Selenium; CoQ10; Lipoic Acid; Pycnogenol
Two or more of the following: Vitamin A-C-E; Selenium; CoQ10; Lipoic Acid; Pycnogenol
Required
How many prescription medications do you take on a regular basis i.e. multiple times a week?
*
None
One
Two
Three
Four or more
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