Nature Reigns Custom Supplement Survey

Nature Reigns Custom Supplement Survey

This intuitive and adaptive survey gives us the ability to learn about your health history and health goals so we can better assist you with product recommendations. We look forward to joining you on your health journey!
General Information
Name*

PrefixFirst NameMiddle NameLast Name
Today's Date*

MonthDayYear
Phone number (Where a health-care professional can call you)*
Email*
Sex:*

MaleFemaleOther
D.O.B *

MonthDayYear
Height*
Weight*
Address where we can ship your supplements*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your occupation?
Were you referred by anyone? (Please list the source or person who has referred you)
Would you like to receive sms/email updates and Promotions?

YesNo
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Email
Supplement Intake
Diet*
Do you have any known allergies or intolerances? If so, please list below*
Your Health Concerns (Please list your health concerns/goals here)*
Do you have a confirmed diagnosis? If so, please list below
Medical History, including surgeries (Please list any and all health conditions or issues in the past or present)*
Family Medical History (Please list any disease or illness in your family)
Have you had any organs or teeth removed? If so, please list below
Medications or Supplements (Please list any medications or supplements you take on a regular basis and the quantity)*
Have you received the Covid Vaccine? If yes, please list the date below
Are you on any Anticoagulants?

YesNo
Do you get up to use the toilet at night?

YesNo
Have you had any dental fillings? If so, please list the tooth number and location
Have you had any root canals? If so, please list the tooth number and location
Toxicity and Symptom Screening
Digestive Tract

Nausea or VomitingDiarrheaConstipationBloating FeelingBelching or Passing GasHeartburnIntestinal/Stomach Pain
Head

HeadachesFaintnessDizzinessInsomnia
Mouth/Throat

Chronic CoughingGagging, frequent need to clear throatSore throat, hoarseness, loss of voiceSwollen, discolored tongue, gums, lipsGums bleedingBad breath
Ears

Itchy ears (total)Earaches, ear infectionsDrainage from earRinging in ear, hearing loss
Heart

Irregular or skipped heartbeatRapid or pounding heartbeatChest pain
Nose

Stuffy noseSinus problemsHay feverSneezing attacksExcessive mucus formation
Emotions

Mood swingsAnxiety, fear or nervousnessAnger, irritability, or aggressivenessDepression
Joints/Muscles

Pain or aches in jointsArthiritisStiffness or limitation of movementPain or aches in musclesFeeling of weakness or tirednessSwollen feetStiffness in feet
Skin

AcneHives, rashes, or dry skinHair lossFlushing or hot flashesExcessive sweating
Energy/Activity

Fatigue, sluggishnessApathy, lethargyHyperactivityRestlessnessRestless legsFidgety
Lungs

Chest congestionAsthma, bronchitisShortness of breathDifficulty breathing
Do you smoke

YesNo
Alcohol use

DailyWeekly1-2 times a monthNone
Have you ever done a detox? Please list the type and how long ago.
Weight

Binge eating/drinkingCraving certain foodsExcessive weightCompulsive eatingWater retentionUnderweight
Eyes

Watery or itchy eyesSwollen, reddened or sticky eyelidsBags or dark circles under eyesBlurred or tunnel vision
Mind

Poor memoryConfusion, poor comprehensionPoor concentrationPoor physical coordinationDifficulty in making decisionsStuttering or stammeringSlurred speechLearning disabilities
Other

Frequent illnessFrequent or urgent urinationGenital itch or discharge
Disclaimers
I fully understand this is a Symptom Survey designed to provide nonclinical information to a Supplement Specialist*

I understand
I fully understand the difference between the practice of allopathic (conventional) medicine, nutritional wellness consulting, and Quantum Cellular Scans*

I understand
I fully understand that any reference to "patient" within this therapy is solely due to technical terminology and in no way implies that the client is a medical patient*

I understand
I fully understand that the attending technician/supplement specialist does not offer allopathic drugs, surgery, chemical stimulants, radiation therapy, or any other conventional treatments. In addition, he/she does not diagnose, treat, or otherwise prescribe for any disease, condition, or illness*

I understand
If I desire any services not provided by the attending Quantum Cellular technician/Supplement Specialist, which is my prerogative, I fully understand that I should seek them elsewhere. A referral for such services can be arranged*

I understand
The Food and Drug Administration has not evaluated these statements. This Symptom Survey is not intended to diagnose, treat, cure or prevent any disease*

I understand
Should be Empty:

Nature Reigns Custom Supplement Survey

General Information

Emergency Contact Information

Supplement Intake

Toxicity and Symptom Screening

Disclaimers