Assessment

1

Name* This field is required.First Last

2

Email* This field is required.

3

How Healthy do you eat?* This field is required.Congrats on making your choice to feel Amazing all throughout the day! Do you feel you eat healthy?

Yes, all the time

Yes, but I have a cheat 1-3x per week

Yes but I cheat daily

Sometimes/Not sure

No, but I try to eat a healthy meal daily

No, but I try to eat healthy often

Not at all

5

Do you currently consume coffee/caffeine?Please select the best answer

Yes, all thru the day (more than 3x)

Yes, a couple times per day

Yes, once a day typically

Yes, a couple times per week

Yes, but infrequently

No, Not at all

Yes, but only before an event/activity

6

Can you tell us of any history or pre-existing health conditions you have had in the past?* This field is required.(i.e. high blood pressure, seizures, myopathies, hypoglycaemia, diabetes, thyroid disorders etc)

*By providing these conditions you declare them to be true.

7

Are you on any medications? If so what are they for?* This field is required.

*By providing these conditions you declare them to be true

8

Take PhotoSubmit your photo now, then again in 2 weeks so you see changes yourself.

9

I attest that the information provided is accurate and to the best of my knowledge. (Print Name)* This field is required.First Last

10

Signature

Clear