Preferred Wellness
60- Second Health Test
Conscious About Your Health and Wellness
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Personal Information
Name
*
First
Last
Email
*
Phone
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Health Information
Check Boxes
*
Low Energy
Wrinkles
Skin Problems
Difficulty Falling Asleep
Occasional Losing Weight
Frequent Bloating
Joint Problems
Belching/Gas After Meals
Muscle Cramps
Health burn/ Indigestion
Menstrual Cramps /PMS
Constipation or Diarrhea
Mood Swings
Brittle Nails /Limp, Dry Hair
Allergies / Hay fever
Difficulty Handling Stress
Hemorrhoids
reduce Layout unwated
Total Number of Checks
*
Are you bothered with unwated facial hair?
Yes
No
Do you draw your eyebrows?
Yes
No
Opioid dependency?
Yes
No
Would you like to reduce belly fat/
Yes
No
Would you like supportive bra without underwire?
Yes
No
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