Immunity Toolbox - Questionnaires

Basic Information
Name & Gender
Date of Birth
Weight(lbs) / Height(inches) / Waist(inches)
Contact Mailing Address


Questions

Q-01


Why would you like to start taking daily supplements?


Q-02


What are your top three health concerns?


Q-03


Do you follow any special diets?


Q-04


Do you have any allergies or try to avoid any of the following?


Q-05


On average, how many servings of fresh fruit and vegetables, do you eat in a day? Keep in mind that one serving of fruits or vegetables is about the size of your fist.


Q-06


How many servings of nutrient dense and nutrient rich (calcium, potassium and antioxidants) foods do you typically eat in a day?


Q-07


How many servings of fish, rich in omega 3 fatty acids or other form of fatty acids (omega 9, omega 7 and omega 6) , do you eat in a week ?


Q-08


On average, how many days a week do you drink alcoholic beverages?


Q-09


Do you currently smoke or come into contact with second hand smoke?


Q-10


Have you had any genetic health testing? (any direct to consumer gene testing)


Q-11


Based on your gene testing, are there significant findings that show your risk for any of the following conditions?


Q-12


Are you trying to lose more than 10 pounds from your weight?


Q-13


Do you regularly keep track of your daily steps or movement thru a mobile app or wearable gadgets?


Q-14


If you are able to measure your daily steps, how many steps are you taking per day?


Q-15


Which best describes your fitness or activity level?


Q-16


Do you get limited sun exposure or use sunscreen daily?


Q-17


Would you like support for your hair, skin and nails?


Q-18


Do you have any of the following skin conditions?


Q-19


Do you experience any of the following?


Q-20


Are you experiencing any urinary symptoms indicative of obstruction or problem with its flow? (hesitancy, intermittency, incontinence)


Q-21


Has anyone in your immediate family had any of the following conditions?


Q-22


Have you been treated with antibiotics in the past 12 months?


Q-23


How is your mood and stress levels?


Q-24


On average, how are your energy levels?


Q-25


On average, how well do you sleep?


Q-26


Do you have any of the following conditions related to your eye, nose and gum health?


Q-27


Do you have any of the following conditions related to your lung health?


Q-28


Do you have any of the following conditions related to your joint and bone health?


Q-29


Do you have any conditions related to your stomach and digestive health?


Q-30


Do you have any conditions related to your kidney and bladder health?


Q-31


Do you have any conditions related to blood sugar and endocrine health?


Q-32


Are you interested in supporting your immune system during cold and flu season?


Q-33


Do you have any of these conditions related your immune or cellular health?


Q-34


Please provide a list of your current maintenance medications (synthetic and conventional drugs only)


Q-35


How much are you willing to allocate from your monthly budget to stay healthy?


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