Let’s Understand What Your Body Is Asking For

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

Format: (000) 000-0000.

E-mail

example@example.com

Date of Birth

What's bothering you most right now?

CURRENT SYMPTOMS (check all that apply)

HEALTH CONDITIONS OR CONCERNS (check all that apply)

How often do you have a bowel movement?

When do you feel your energy drop the most?

How much water do you drink a day?

Which of the following do you regularly consume? (check all that apply)

How would you describe your current lifestyle?

GOALS OR AREAS YOU’D LIKE TO IMPROVE (check all that apply)

Please list any prescription or over the counter medications you are currently taking (this helps me ensure your protocol is safe and supportive for your body) ***If you have images / files of your list, you can upload below

Please list any current medications or supplements you’re taking so I can ensure your recommendations are safe and supportive for your body. ie. Omega3, Collagen, Daily Vitamins, Amino Acids, Creatine, Electrolytes, Protein Supplement, Sleep Aids, Zinc, Echinacea, Turmeric, CoQ10 ***If you have images / files of your list, you can upload below

***Please upload med/supplement list images / files here (if available)

Has your healthcare provider mentioned anything you should avoid or limit when it comes to supplements or nutrition?

How ready are you to make changes?

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.