| Name: |
|
| Address: |
|
| City: |
|
| State: |
Zip: |
| eMail: |
|
| Date of Birth: |
|
| Marital Status: |
|
| How many children under 12 in your house? |
|
| How many times a week do you exercise? |
|
| Occupation: |
Homemaker
Professional/Technical
Upper Mgmt./Administration
Craftsman/Tradesman
Sales/Service/Middle Mgmt.
Clerical/White Collar |
Do you or a member of your family suffer from any of the following?
(Check all that apply) |
Cancer
Diabetes
Osteoporosis
Alzheimer's
Heart/Circulation Problems
Parkinson's
Arthritis |
| What products do you buy in your health food store? |
Vitamins
Health and Beauty Aids
Herbs
Other Supplements
Organic Products
Weight Loss |
| What types of complementary health care do you use? |
Homeopathy
Acupuncture
Ayurveda
Aromatherapy
Naturopathy
Massage Therapy
Chiropractor |
Do you experience any of the following?
(check all that apply) |
Lack Of Energy
Migraines
Excess Stress
Allergies
Menopause
Sleeping Disorders
Memory Loss
Irregularity |
| |
|
