60- Second Health Test – Conscious About Your Health and Wellness

60-Second Health Test

Preferred Medi Spa

In just 60 seconds,
learn what you need to
improve your health

Do you have any of these
occasional symptoms?

Use a checkmark (✔) to note
the conditions that affect you.

Rose Slaughter, RN Wholistic Nurse
Kim Staten-Smith, RN Wholistic Nurse
Cora Young, RN Wholistic Nurse

Personal Information

Name *

First

Last

Layout

Email *

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Health Information

Checkboxes

Low Energy
Wrinkles
Skin Problems
Difficulty Falling Asleep
Occasional Losing Weight
Frequent Bloating
Joint Problems
Belching/Gas After Meals
Muscle Cramps
Heartburn/Indigestion
Menstrual Cramps/PMS
Constipation or Diarrhea
Mood Swings
Brittle Nails/Limp, Dry Hair
Allergies/Hayfever
Difficulty Handling Stress
Hemorrhoids
Frequent Colds
Poor Memory

Number of check boxes *

Layout

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