Well World Wellness Survey

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Referrer
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code
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practiceid
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Hello!* This field is required.To provide you with a personalized supplement protocol, please fill out the following questions.
First Name
Last Name
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Email* This field is required.
example@example.com
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Age range* This field is required.
< 29
In my 30's
In my 40's
In my 50's
60 +
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Your biological gender* This field is required.Nutritional requirements differ between men and women, as they do between adults and children, due to many factors. Governmental guidelines and the Institute for Medicine nutritional guidelines reflect these differences as it pertains to both macro and micronutrient intake requirements. Examples include the fact that biological men generally have a greater muscle mass and density, therefore they require higher levels of protein and calories per day. Women who are actively having menstrual periods require a higher level of iron intake to replace losses from menses. Pregnant and lactating women require more fat and calories, as well as higher levels of micronutrients necessary from proper fetal development. Older women have higher calcium intake requirements to maintain proper bone health. These are just several examples of why knowing factors such as gender, age, menstrual status, pregnancy and lactation status, all result in the ability to make more precise and higher quality recommendations for nutrient intake, and therefore informs supplement recommendations.
Female
Male
Prefer not to say
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Weight* This field is required.
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Height* This field is required.
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What are your top three health goals right now? * This field is required.(Chose up to 3)
Support for a specific area of my health
Improve my general health and wellness
Support my immune system
Increase my energy and stamina
Get restful sleep
Support brain health (memory, focus, sharpness)
Relieve stress
Maintain healthy skin and hair
Gain lean muscle (or maintain it)
Reduce my body fat percentage
Improve my athletic performance / improve my workouts
Support for seasonal allergies
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Specific health conditions - male* This field is required.Choose a maximum of 2 of the following health conditions
Indigestion (repeating of food, gas, bloating)
Prostate health
Eye health
Liver health and better detoxification
Blood pressure
Cholesterol
Blood sugar control
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Specific health conditions - female* This field is required.Choose a maximum of 2 of the following health conditions
Indigestion (repeating of food, gas, bloating)
Eye health
Liver health and better detoxification
Blood pressure
Cholesterol
Blood sugar control
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Do you take a PPI or other acid-reducing medication?* This field is required.
YESNO
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Do you take a statin medication?* This field is required.
YESNO
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Do you take a medication for blood sugar control?* This field is required.
YESNO
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Your daily fruit and vegetable intake* This field is required.(select one)
2 or fewer servings per day
3+ servings per day
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Your daily hydration (water) intake* This field is required.(select one)
5 or fewer 8 oz glasses per day
6 - 7 glasses per day
8+ glasses per day
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Your daily alcohol intake* This field is required.(select one)
I don't ever or I rarely drink alcohol
I consume moderate alcohol three or more times a week (1-2 glasses of wine or beer)
I often have more than two glasses per day
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Your joint stress activities* This field is required.Do you, or have you, engaged in sports and activities that place great stress on your joints?
YESNO
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Your gut health (microbiome)* This field is required.(select all that apply)
I have had antibiotics in the past year or did frequently in the past (childhood)
I often have gas and bloating
I often have indigestion (heartburn, nausea, belching, repeating of food)
I frequently have diarrhea or soft stools
I often deal with constipation
None of the above
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Do you take a PPI or other acid-reducing medication?* This field is required.
YESNO
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Your typical energy level* This field is required.(choose one)
I am exhausted throughout the day
I have a lot of energy thoughout the day
My mind is racing and I have a hard time settling down at night
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Your general stress level* This field is required.(choose one)
I have a lot of stress at work
I have a lot of stress at home
I have a lot of stress at home and at work
I don't have a lot of stress in my life
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How many hours of sleep do you typically get at night?* This field is required.(choose one)
< 6 hours
6+ hours
7+ hours
8+ hours
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Which sleep pattern describes you?* This field is required.(choose one)
I usually sleep quite well
I have a hard time falling asleep and my mind races
I have a hard time staying asleep
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How is your focus and memory?* This field is required.(choose all that apply)
I want to maximize my brain function (focus, sharpness, memory)
I am prone to missing appointments and misplacing items
I sometimes forget the names of people I know quite well (friends, colleagues, family members)
I have difficulty with attention and staying on task. My brain's sharpness and memory isn't what it used to be
None of the above
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How are your skin, hair and nails?* This field is required.(choose all that apply)
Skin: I am interested in reducing fine lines and wrinkles as I age
Skin: I'd like my complexion to be more even
Hair: I have difficulty growing my hair to the length I would like
Hair: I'd like to improve the texture and shine of my hair
Nails: My nails break easily and aren't as strong as I would like
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How is your menstrual cycle?* This field is required.(choose one)
Currently menstruating
Post-menopause / hysterectomy
Not currently menstruating due to birth control, etc.
I am pregnant
I am breast feeding / pumping
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Are you sensitive to any of the following allergens?* This field is required.(check all that apply)
Dairy
Eggs
Seafood
Shellfish
Peanuts
Tree Nuts
Soy
Wheat / Gluten
None
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Are you vegan or vegetarian?* This field is required.(select one)
Vegetarian (vegetables, eggs, milk, cheese)
Vegan (only vegetables)
I am not vegan or vegetarian
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Vegan or Vegetarian* This field is required.Since you are a vegan or vegetarian, we will not recommend certain supplements that contain ingredients that will conflict with your dietary choices or requirements. Would you prefer to consider a wider array of supplement options that may contain animal or dairy-derived ingredients?
YESNO
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