Tell us about you !

 

NUTRITIONAL
QUESTIONNAIRE

*First Name:

*Last Name:
Fax:
*email:
How did you hear about us?
Present Medical Conditions:
(list all)
Current Nutritional Supplements,
  non- prescription:
(list all)
Nutritional Supplements, non- prescription:
(list all)

Are you presently under
physician's treatment?

      Yes      No
Are You taking any Medication(s)?
List for what condition?
Present medical treatment
 for your condition:
List major symptoms that 
affect you daily be specific:
Are you Allergic to any medications 
or supplements?:

  Your Age  Your Gender:     Your Ht:     Your Wt: If Partner, Sex:
Please indicate you specific 
health needs:
Parent's medical history:
Please tell us if you are a smoker
(How many cigarettes per day?)
Please indicate any hormonal 
or glandular problems:
Any other information:

                            The information that you provide us with will be completely confidential.
                                              We DO NOT share or sell our client files or e-mails.  

This information will be evaluated and a specific natural supplement plan will be created for you based on the information
you have provided. This plan is not intended to treat or cure an illness. If you have an existing condition, you may need
a thorough medical examination to determine the condition, the severity of the condition and any remedial action. We
are not attempting to replace your General Health Practitioner, and accept no responsibility for your health, or the
out-come of taking any dietary supplements that might be recommended.

Taking herbs, and vitamins as dietary supplements may improve your health and vitality, and provide your body with a
safe and natural resistance against common ailments. However, *statements made at this web site have not been
evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any
diseases.

*(required fields)                                               

  

For any questions or orders by fax.  Please e-mail us at health4u@gate.net or call us at (561)435-4895 Eastern time. 

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