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Health Survey

The representative of this product would like for you to provide answers to the following health related questions. This will help them best serve your needs and determine whether you qualify

for the free sample offer. Please take a few minutes and complete the form below and then click on submit. Thank you.

What age group are you in?
Under 20 20s 30's 40's 50's 60's 70's 80+

What is the main reason you would like to try the product?
I would like to take vitamins.
A friend told me about the product.
It looks like a good product to take.
I'm looking for an easy to take product.
Other

Have you taken supplements before? Yes No

If so, what were the results? Excellent Good Fair Poor N/A

I would like to take a product that would help prevent heart disease. Yes No

I need to lower my cholesterol. Yes No

Do you, or someone in your household have respiratory
problems such as asthma/allergies? Yes No
I would like to lose weight. Yes No

If yes, please indicate how much weight you'd like to lose:
5-10 lbs 10-20 lbs 20-30 lbs 30+ lbs

I would like relief from stress. Yes No

Do you suffer from joint pain? Yes No

Do you crave carbohydrates and/or sweets? Yes No

Do you have energy drops/low blood sugar? Yes No

I suffer from frequent colds and flu. Yes No

I am interested in receiving free information about targeted solutions for the following areas (mark all that apply):
Digestive Health - including lactose intolerance, IBS
Women's Health - including PMS, menopause solutions
Men's Health - including prostate health
Children's Health - including ADD/ADHD
Sports Nutrition

Do you currently spend more than $20 per month on nutritional supplements? Yes No

Have you ever purchased anything online? Yes No

Please feel free to type in any comments here that might help us better understand your level of interest in trying our product.

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