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  5. Health Questionnaire
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Questions marked with a * are required Exit Survey
 
 
* If I had a magic wand and could give you anything that you want, anything at all right now in your life….what would that be?
   
 
 
 
* What is your main health concern?  Please select all that apply.
 
Weight
 
Energy
 
Diet
 
Mental Health
 
Issues on or in your physical body

 
 
 
* What have you done in the past to work on this health condition (include both alternative and traditional modalities)?
   
 
 
 
* What has proven effective?
   
 
 
 
* What is your current diet like? Please be specific here
   
 
 
 
* Are you currently taking any supplements?
 
Yes
 
No
 
 
 
* If you answered, Yes above, which supplements are you taking?
   
 
 
 
* Are you currently taking any long term prescription medications?
 
Yes
 
No
 
 
 
* What are the main reasons that you are not reaching your health goals?