Immunity Toolbox - Questionnaires
| Name & Gender |
| Date of Birth |
| Weight(lbs) / Height(inches) / Waist(inches) |
| Contact
Mailing Address |
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?
Email: