Vitality Assessment

Vitality Assessment
Fill out the quick quiz below to find out what you could use to support your health and wellness, naturally.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
My sleep is satisfying and I awake feeling rested.

Never Seldom Sometimes Often Always
I live my life free of chronic aches & pains.

Never Seldom Sometimes Often Always
I have a strong immune system & resist getting sick.

Never Seldom Sometimes Often Always
I am emotionally balanced & not stressed or anxious.

Never Seldom Sometimes Often Always
I have energy & vitality throughout the day.

Never Seldom Sometimes Often Always
My mental focus & memory are quick & sharp.

Never Seldom Sometimes Often Always
My hair, skin & nails are healthy & beautiful.

Never Seldom Sometimes Often Always
What are your main health concerns for you and/or your family?

Sleep Muscle & Joint Pain Stress & Anxiety Focus & Concentration Immune Support Allergies Digestive Issues Headache & Migraines Respiratory Issues Energy & Fatigue Hormonal Issues Weight Reduction Skin Conditions Mood & Emotions
Would any of these lifestyle changes support you in reaching your health goals?

Increased Water Intake Diet Changes More Exercise Better Sleep
Which of the following products do you already use?

Multi Vitamins & Minerals Omega oils Probiotics Digestive Aids/ Antacids Herbal Supplements/ Sleep aids Hand Wash Bar Soap Bath/Shower Gel Hand/ Body lotion Skin Care (Cleanse, Tone, Moisturizer) Lip Balm Deodorant Toothpaste/ Mouthwash Shampoo & Conditioner Laundry Detergent Cleaning Products Air Fresheners Muscle Rubs Pain Killers Weight loss products Energy Supplements/ Drinks Power Greens/Superfoods Cough / Cold Remedies First Aid Ointment Cream
Where do you typically purchase these products from and do you earn cash back orrebates from these store?
Are you currently working with a dōTERRA Wellness Advocate?

Yes No
Who Are You Working with
Do you already have a dōTERRA wholesale membership account?

Yes No
Which of the following are you interested in learning more about?

Learning More About Oils Sharing doTERRA as a hostess to get free stuff Being a VIP Customer and saving 25% Product Consultant Opportunity - Earn $
Address (Optional)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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