Personalized Wellness Assessment:
(2-5 minutes) Fill out this short wellness survey to receive your personalized health, supplement, and lifestyle recommendations based on your goals, symptoms, and current health status.
Section 1: Basic Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Gender
Male
Female
Prefer not to say
Section 2: Health Goals
What are your top 3 health goals?
What are you primarily looking for?
Energy
Weight management
Digestion
Detox/cleanse
Hormonal balance
Mental clarity
Immune support
Sleep
Skin health
Muscle building
General wellness
Other
Section 3: Current Status
How would you describe your current health status?
*
Excellent
Good
Average
Below average
Poor
How is your energy level?
Very low
Low
Moderate
High
How many hours of sleep do you get on average per night?
What's your sleep quality?
Poor
Fair
Good
Excellent
How often do you exercise?
Never
1-2x/week
3-4x/week
5+/week
Section 4: Body Signals & Symptoms
Select all that apply:
Bloating
Constipation
Gas
Loose bowels
Acid reflux
Fatigue
Brain Fog
Sugar cravings
Weight gain
Water retention/puffiness
Joint discomfort
Poor sleep
Skin issues
Hormonal imbalance
Frequent illness
Headaches
Midday energy crashes
Difficulty concentrating
Memory lapses/forgetfulness
Feeling unmotivated or sluggish
Bad breath or body odor
Sensitivity to smells/chemicals
Frequent nighttime urination
Dark or strong-smelling urine
Mood swings
Low libido
Cold hands and feet
Tingling or numbness
Body discomfort/pain
Skin/hair, aging concerns
Section 5: Lifestyle & Background
Do you have any diagnosed conditions? (Feel free to list or explain here.)
Are you currently taking any supplements or medications? (Feel free to list here.)
Do you have any allergies or sensitivities that we should be aware of?
Section 6: Nutrition & Habits
How would you describe your diet?
Poor
Average
Good
Very healthy
Daily water intake
Low
Moderate
High
Do you consume: (check all that apply)
Coffee
Alcohol
Sugar frequently
Processed foods
Section 7: Detox & Internal Health
Have you ever done a detox or cleanse before?
Yes
No
Do you feel like your body needs a detox?
Yes
No
Not sure
Section 8: Scan Results (optional but powerful)
Have you been assessed through a Quantum Bioscan?
Yes
No
No, but I would like to get scanned.
Upload your scan results here, if you have them (PDF file upload):
Browse Files
Drag and drop files here
Choose a file
Cancel
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Section 9: Budget & Commitment
How much do you currently spend on health products monthly?
$0-50
$50-100
$100-200
$200+
What are you willing to spend, your monthly investment in your health?
$50-100
$100-200
$200-300
$300+
When would you like to do something about your health?
Now!
Next week
Next month
In the next 6 months
Other
Section 10: Perks & Membership
Would you like to earn loyalty rewards on your monthly orders, that you can use to get up to 80% off your products?
Yes
No
Tell me more!
Would you be open to any of the following?
Getting products at wholesale pricing (20-40% off)
Earning loyalty credits/free products
Referring friends & earning monetary rewards
Starting a wellness business of your own
Using the Bioscanner for personal or business use
Retailing products to stock and sell in a store, clinic or wellness center
Adding products to your virtual or online store
Vital Health offers up to 54% in monetary rewards and the opportunity to purchase products at up to 80% off, the manufacturer cost.
Is there anything specific you'd like help with or ask about? (type here)
Consent & Disclaimer:
• I understand these products are designed to support overall wellness and are not intended to diagnose, treat, cure, or prevent any disease. • I understand my answers to this survey are confidential and only being shared to the person helping with my assessment and not being shared directly with the company or other representatives. • I agree to be contacted with my personalized wellness plan and product recommendations.
Signature
*
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