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Health Assessment

Choosing health supplements can be confusing. Our FREE HEALTH ASSESSMENT form individualizes your daily health issues and needs and takes just 1-2 minutes to fill out. After completing this form, we will contact you to advise you on the best supplements for your overall health and wellness.

  • For best results, please select 6-8 health issues that currently concern you the most. This is not your family medical history and should include only conditions that affect you. To get started, check the box beside your selected health issue.

    Acid Indigestion


    Bloating, Constipation


    Difficulty Sleeping

    Dry Hair

    Oily Hair

    Grey Hair

    Thinning Hair

    Dry Skin

    Heart Disease

    High Blood Pressure

    High Cholesterol

    Joint Pain/Arthritis

    Lack of Energy

    Loss of Memory

    Low Sex Drive



    Overeating with Sugar Cravings

    Overeating without Sugar Cravings


    Prostate Issues

    Thyroid Problems

    Vision Issues

    Yeast/Fungal Infections



    Mood Swings


    Low Immunity

  • Please specify any other health issues not listed above:

  • Daily Medications & Supplements List all prescription and over-the-counter medications you are currently taking regularly:

  • List all vitamins, nutritional supplements, etc., that you are currently taking regularly:

  • List all allergies & sensitivities that affect you, and check below if you are sensitive to caffeine:

  • IMPORTANT: Please consult with your physician or other health care provider if you have a medical condition, including ANY disease or health issue related to kidney or kidney function (excluding UTI), prior to use of any supplement as suggested upon completion of this health consultation form. 

  • Diet & Exercise
    Approximately how many meals do you eat per day?

    • 1 meal a day
    • 2 meals a day
    • 3 meals a day
    • 4 meals a day
    • 5-6 meals a day
  • Please choose one of the following that best describes your activity level:

    • Sedentary (No regular exercise)

    • Walking (1-3 miles daily)

    • Active Lifestyle (No specific exercise regimen)

    • Moderate Exercise Program (4-5 times per week for 30-45 minutes)

    • Vigorous Exercise Program (6-7 times per week for 45-75 minutes)

Your Details

    • Male
    • Female
  • Submit
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