Discover What Your Body Really Needs

Discover What Your Body Really Needs
Please fill out this short questionnaire to help us gain insight into your current health and wellness goals.

Let’s explore what your body is telling you. Your responses will guide us in creating a wellness protocol aligned with your unique needs and goals.

*All information is confidential and used only for wellness guidance.
Full Name*

First NameLast Name
Phone Number*
E-mail
example@example.com
CURRENT SYMPTOMS (check all that apply)

Low energy or fatigueDifficulty sleeping or poor-quality sleepBrain fog or trouble concentratingMood swings or low moodDigestive issues (bloating, gas, sluggish digestion)Hormone imbalances (PMS, menopause, low libido, etc.)Skin concerns (breakouts, dullness, dryness)Joint pain, stiffness, or inflammationFrequent sugar cravingsWeakened immunity or frequent illnessNone of these
HEALTH CONDITIONS OR CONCERNS(check all that apply)

Inflammation or chronic painHigh blood pressureBlood Sugar Issues / DiabetesLiver or kidney stressLung or breathing challengesHormone imbalancesSkin Breakouts or Dull SkinJoint Pain or StiffnessLow immunity or frequent infectionsGut conditions (IBS, constipation, ulcers, etc.)Thyroid imbalance or hormone-related issuesHeadachesOther:
GOALS OR AREAS YOU’D LIKE TO IMPROVE(check all that apply)

(Check all that apply)Increase daily energy and focusImprove sleep quality and recoverySupport gut health and digestionBalance hormones and moodStrengthen immune systemReduce inflammation or joint pain Improve mental clarity and memorySupport healthy weight management Enhance skin, hair, and nail healthBuild muscle strength or performanceSupport detoxification and liver functionCreate overall balance and long-term vitalityOther:
Is there anything else you’d like me to know that would help me personalize your supplement protocol?
Please list any current medications or supplements you’re taking so I can ensure your recommendations are safe and supportive for your body.
Has your healthcare provider mentioned anything you should avoid or limit when it comes to supplements or nutrition?
I understand and agree that the information and supplement recommendations provided by Vital Health are for educational and wellness purposes only. They are not intended to diagnose, treat, cure, or prevent any medical condition. I acknowledge that I should always consult my physician or qualified healthcare provider before starting any new supplement, especially if I am taking medications, have existing health conditions, or am under medical supervision.

I understand and agree
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