CustomVite Personalized Nutritional Supplements

First Name

Last Name

Street

City

State

Zip Code

Home Phone

Mobile

Email

Height

Weight

Age

Gender

Marital Status

Number of Children

Occupation

List any Medications you are taking and what it is prescribed for (i.e. Lipitor to treat cholestorol)

List any Vitamins, Minerals, of Herbal supplements you are currently taking and their respective doses

Do you have trouble swallowing pills?

Trouble swallowing multiple pills?

Are you overweight?

If so, by how many lbs.?

Are you trying to lose weight?

Do you exercise?

How often per week?

Do you compete professionally?

Do you smoke?

If yes, how many per day?

If yes, are you trying to quit?

Do you have any allergies?

If yes, please specify (i.e. seasonal, medications, foods, etc.

Do you have any trouble with infections?

If yes, plese specify (i.e. sinus, yeast, etc.)

Have you used antibiotics within the past two years?

Is your blood pressure

Level?

Is your cholestorol

Level?

Do you have a racing heart?

Dizzy spells?

Circulatory problems

Do you have aching joints or muscles?

Swollen or puffy joints?

Have you had a head injury, trauma or major surgery?

If yes, specify date

Do you experience any twitching?

Back problems?

Do you bruise easily?

Do you have acne?

Do you have dry skin?

Hair Loss

Thin Hair?

Women Only:

Are you pregnant?

Currently breast feeding?

Menopausal?

Briefly state your current health condidtion (i.e. obesity, heart disease, cancer, ulcer, lactose intolerance, etc.)

List any familial difficulties such as obesity, heart disease, cancer, genetic diseases, errors of metabolism or other concerns

_______________________________________________________

Please answer all of the questions below

At night, do lights of oncoming cars bother your eyes?

Does bright sunshine ever cause pain in your eyes?

Do you have small bumps on the back of your upper arm which makes the skin feel rough?

Are you prone to cysts, sties, acne or boils?

Have you ever experienced deep bone pain in the thigh bone?

Do you heal slowly, get frequent colds or other infections?

Do you have any sores that won’t heal, like hemorrhoids?

Do your nails and hair grow slowly?

_______________________________________________________

Are you troubled with dermatitis?

Do you have flaky or crusty skin around the edge of your scalp?

Do you sometimes feel moody, depressed or stressed out?

Are you on the birth control pill?

Are you troubled with gastrointestinal problems?

In the morning do you notice if your fingers are swollen or if your rings feel too tight?

Are you nervous and feel unable to relax?

Is your tongue scalloped around the edges where it rests against the teeth?

Is your tongue a bright cherry color?

Do you have trouble with your memory and the ability to concentrate?

_______________________________________________________

Do your gums bleed when you brush your teeth?

Are hives or itching skin a problem for you?

Are you exposed to industrial chemicals, fertilizers, sprays, paints, insecticides or solvents?

_______________________________________________________

Is there a history of osteoporosis in your family?

Has your dentist become concerned with periodontal disease or observed the development of spaces between your gums and teeth?

Have you lost more than 4 permanent teeth?

Have you taken any steroids for more than 6 weeks?

Do you have a history of kidney disease?

_______________________________________________________

Have you ever had heart disease?

Do you have circulation problems?

Do you have any stretch marks on the skin?

Are varicose veins visible?

Have you taken more than 800 IU of vitamin E (daily) for several years?

Do you sometimes get nosebleeds for no particular reason?

Are you experiencing trouble with hot flashes?

_______________________________________________________

Do you have a history of bladder problems or kidney stones?

Do you have trouble sleeping through the night?

On exertion, do you get foot or leg cramps?

Do you have trouble with migraine headaches?

Is your heart rhythm irregular for no apparent reason?

Do you ever feel completely drained and find that you are crying for no particular reason?

Have you been experiencing an unusual pattern in terms of bowel movements, diarrhea or constipation?

Are you bothered by noises that seem too loud?

Do you crave sugar?

_______________________________________________________

Are you vegetarian?

Do you feel tired all the time?

Are your fingernails a pale white color?

Do you menstruate heavily?

Do you often feel short of breath, or sigh frequently?

Are unexplained nosebleeds common?

Have you been troubled by or are concerned with the following (please check “yes” for all that apply):

Uterine fibroid tumors

Colon cancer

Prostate problems or cancer

Fibromyalgia

Choose a category

_______________________________________________________

Is there any information about yourself you would like us to know that was not asked in the questionnaire?

If yes, please be specific.

_______________________________________________________

CustomVite® is pleased to offer this Automatic Re-order Program. By signing up with our automatic re-order program, you will receive your supplements on a regular basis. You will not have to worry about calling to place an order before you run out.

By setting up this automatic re-order, you are giving us permission to ship your order automatically every 3 months and charge it to your credit card. As always, your credit card will not be billed until the order is processed.

First Name

Last Name

Billing Address

City

State

Zip Code

Country

Order #

Re-Order Amount

By becoming part of our Automatic Re-Order Program you receive FREE shipping!

I authorize NutriLab, LLC to charge my chosen method of payment for the amount selected above every month. I understand that I can cancel this standing Re-Order at any time by simply calling our customer service department at 1-800-379-9979 or by sending an e-mail message to: service@nutrilab.com. In the event that I cancel my Re-Order prior to this time period, I agree to pay all freight charges that were initially waived.

I want to save an extra 5% on my total bill. I authorize NutriLab, LLC to charge my chosen method of payment for my full three-month supply and for each additional three-month supply thereafter. I understand that I can cancel this standing Re-Order at any timeby simply calling our customer service department at 1-800-379-9979 or by sending an e-mail message to: service@nutrilab.com. In the event that I cancel my Re-Order prior to this time period, I agree to pay all freight charges that were initially waived.

Card Number

Exp. Date

Confidential Lifestyle And Medical History Questionnaire

AUTOMATIC RE-ORDER PROGRAM

Payment Option 1: Pay Monthly

Payment Option 2: Pay in full for each 3-month supply and save 5%

PAYMENT METHOD: Please charge my credit card: