Initial Health & Vitality Questionnaire

[[trackingImage]]

Initial Health and Vitality Questionnaire

* Name

0/50

* Email for results and supplement recommendations

0/50

* Date of birth 00/00/00

0/50

* Current weight (lbs)

0/50

* Height (ft)

0/50

* Weight Regulation: Do you currently experience difficulty losing weight or maintaining a healthy weight, despite diet or lifestyle efforts?

Yes

Unsure

* Sleep Quality: How would you describe your sleep?

Difficulty falling asleep

Difficulty staying asleep

Wake feeling unrefreshed

Sleep is deep and restorative

* Energy, Focus, and Fatigue: Do you experience fatigue, brain fog, poor focus, or energy crashes during the day?

Frequently

Occasionally

Rarely

Never

* Joint Health & Inflammation: Do you experience joint pain, stiffness, inflammation, or discomfort?

Yes - Mild

Yes - Moderate

Yes - Severe

Digestive Function (Bowel Health): How often do you have a bowel movement?

1 time per day

2 times per day

3-4 times per day

Less than once per day

* Immune Resilience: On average, how many times per year do you get sick (colds, flu, infections)?

0-1

2-3

4-5

Hormones & Vital Drive: How would you rate your sexual drive, hormonal balance, and overall vitality?

Poor

Fair

Good

Excellent

* Memory & Cognitive Performance: How is your memory, recall, and mental sharpness?

Poor

Fair

Good

Excellent

* Hair, Skin, and Nails: How would you describe the health and quality of your hair, skin, and nails?

Poor

Fair

Good

Excellent

* Allergies & Sensitivities: Are you prone to allergies, food sensitivities, chemical sensitivities, or environmental reactions?

Yes

Unsure

Submit Survey

Vital Health Scans | 19430 Ryan Dr | Macomb, MI 48042 US

Constant Contact Data Notice