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1. Please rate your energy level throughout the day. (1 being the low and 5 being good)
2. Do you find yourself having trouble concentrating throughout the day?
3. How many hours are you sleeping at night?
4. Please describe how well you sleep at night.
Fall asleep, stay asleep
Wake up once At what time?
Wake up several times
Fall asleep right before alarm goes off
5. Do you have issues with bowel movements?
6. Are you suffering from indigestion? Yes (Please rate below)No, my digestion works great
7. Do you smoke?
Yes How many packs per day?
8. Do you drink alcohol?
9. Do you suffer from joint pain and stiffness?
10. Do you exercise? NoYes, what kind of exercise?
B.Weight LiftingHow often?
11. Are you satisfied with your weight?
No, I would like to LOSE some weight
No, I would like to GAIN some weight
12. Do you have any diet restrictions?
(Recommended for vegetarians: Omega 3s, B12, calcium, D3)
13. How many fruits and veggies do you eat per day?
(Recommended: 1.5 cups of fruits; 2–2.5 cups of vegetables)
14. Are there any other areas of health that you have questions about? If yes, please check all that apply.
Omega 3/Fish Oil
Bone & Joint Health
Stress & Adrenal Support
15. Are you interested in becoming a member of our Pro-Balance Reward Program?
Yes, tell me more!
No, not at this time.