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
Low energy
Low energy
Wrinkles
Wrinkles
Skin Problems
Skin Problems
Difficulty Falling Asleep
Difficulty Falling Asleep
Occasional Losing Weight
Occasional Losing Weight
Frequent Bloating
Frequent Bloating
Joint Problems
Joint Problems
Belching/Gas After Meals
Belching/Gas After Meals
Muscle Cramps
Muscle Cramps
Heartburn/Indigestion
Heartburn/Indigestion
Menstrual Cramps/PMS
Menstrual Cramps/PMS
Constipation or Diarrhea
Constipation or Diarrhea
Mood Swings
Mood Swings
Brittle Nails/Limp, Dry Hair
Brittle Nails/Limp, Dry Hair
Water Retention
Water Retention
Hair Loss
Hair Loss
Hot Flashes/Night Sweats
Hot Flashes/Night Sweats
Allergies/Hayfever
Allergies/Hayfever
Difficulty Handling Stress
Difficulty Handling Stress
Hemorrhoids
Hemorrhoids
Frequent Colds
Frequent Colds
Body Odor
Body Odor
Poor Memory
Poor Memory
Low Endurance Level
Low Endurance Level
Cravings for Sweets/Salts
Cravings for Sweets/Salts
Problems with Yeast/Fungus
Problems with Yeast/Fungus
Cellulite
Cellulite
Total Number of Check Boxes
First Name
Last Name
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Zip
City
State
Address 1
Address 2
Email
Phone
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