JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Take our simple health quiz to get daily a vitamin tailored to your goals, lifestyle, and diet.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Are you male or female?
*
Male
Female
How old are you?
*
Your answer
In general, how much stress do you have in life?
*
0 = None at all
0
1
2
3
4
5
6
7
8
9
9 = A lot, constantly
In general, how are your energy levels?
0 = Very Low
0
1
2
3
4
5
6
7
8
9
9 = Very High
Clear selection
Do you regularly struggle to fall asleep?
*
Yes
No
Do you regularly struggle to get up in the morning?
*
Yes
No
How many hours do you exercise a week?
*
0
1-2
2-5
5+
How often do you get colds?
*
Rarely
More than 3 a year
How often do you smoke cigarettes?
*
None
Seldom
Less than 10 a day
More than 10 a day
Are you on any restrictive diets?
*
No
Vegetarian
Vegan
Pescetarian
Paleo
Gluten-free
Dairy-free
Other:
How many portions of fruit and veg do you eat per week?
*
None
1-5
6-14
14+
How many servings of eggs, nuts & seeds, and soy products do you eat per week?
*
None
1-3
4-6
7+
How many units of alcohol do you drink in an average week?
*
(1 shot of spirit is 1 unit, a medium glass of wine or pint of beer is approximately 2 units.)
None
1-8
8 or more
How many caffeinated drinks do you consume each week?
*
0
1-3
4-6
7 or more
In an average week, how many soft drinks, juices and sugary beverages do you consume?
*
None
1-3
4-6
7 or more
Is there anything you're particularly concerned about or want to improve?
*
No
Immune system
Weight loss
Bone health
Stress relief
Hair or skin or nails
Anti-ageing
Low energy
Digestion
Sleep
Fitness performance
Joint health
Depression
Anxiety
Required
Has your doctor recommended to take vitamin D or iron?
*
Yes
No
Do you take any prescription medications?
If yes, write down the name of the medication here, if no, skip the question
Your answer
Are you currently trying for a baby, pregnant or have you recently given birth?
*
If you are male, simply select "None of the above"
I'm trying for a baby
I'm pregnant
I'm breastfeeding
None of the above
Do you have any allergies, intolerances or sensitivities?
If yes, let us know what they are below, you may skip this question if you don't have any.
Your answer
Do you need support with digestion? Write down your gut symptoms below
If yes, let us know what they are below, you may skip this question if you don't have any.
Your answer
How much would you like to spend on your supplements per month
*
Your answer
Next
Page 1 of 2
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Help Forms improve
Report