Please type in full name
Street Address:
City and State
Enter Birthdate (mo,day,year)
1. Have you been on herbal remedies before today?
2. Are you presently treating any conditions or disease states
with herbal remedies?
3. Are you presently having success with using the herbal
remedies recently purchased?
Great success
Moderate success
Slight success
4. Are you presently on Prescription medications for treatment of
these conditions?
5. Please check the appropriate box for the number of
Prescription medications currently receiving.
1 to 2
2 to 4
4 to 6
More than 6
6. Please check appropriate boxes of diseases or conditions
affecting you.
Diabetes
Lupus
Fibromyalgia
Chronic Fatigue
ADHD
Allergies
7. Would you like information on any of these conditions checked
above treatable by Nutraceuticals?
8. Have you tried taking Nutraceuticals before for any of these
conditions?
9. Are you currently on a diet plan for these conditions?
Enter commments in this area:
