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Health Assessment Test

Directions: Answer the following questions, then click on the bar below each question to identify the vitamin supplementation that corresponds with the concern identified in the question and check all items that you are interested in or interested in learning more about. When you reach the end of the questionnaire, click the "Submit Test" button to send the questionnaire in.


Name*:
eMail Address*:
Phone:
Address:
City, ST, Zip:

Would you like a personal consultation with one of our Doctors or Wellness Specialists?*
Yes    No

How did you hear about Whitacre Wellness?
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Newspaper: 
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* Required Information


Question 1

Do you currently take a multivitamin?
       Yes
      If yes what brand?
       No

       Nutrilite Women's or Men's Supplement Pack

Question 2

Do you suffer from any of the following:
       Inflammation & Swelling
       Muscle Aches
       Joint Pain
       Digestive Problems
       Gas/Bloating
       Acid Reflux/Heart Burn
       Chronic Constipation
       High Cholesterol
       Dull Skin & Hair
       Poor Focus, Clarity & Concentratioin
       Weakened Immune System
       Anemia
       Having Trouble Sleeping
       Low Energy/Fatigue

Inflammation & Swelling
       Ocean Essentials Balanced Health-Omega 3
Muscle Aches
       Ocean Essentials Balanced Health-Omega 3
       Cal Mag D
       Tri-Iron Folic Acid
       XS Energy Drinks
Joint-Pain
       Ocean Essentials Balanced Health-Omega 3
       Glucosamine 7
       Raspberry Joint-Health twist Tubes
Digestive Problems
       Digestive Enzyme
       Intestiflora (Pro-biotic)
       Invisifiber
Gas/Bloating
       Intestiflora (Pro-biotic)
Acid Reflux/Heart Burn
       Digestive Enzyme
Chronic Constipation
       Intestiflora
       Invisifiber
High Cholesterol
       Ocean Essentials Balanced Health-Omega 3
       Invisifiber
Dull Skin & Hair
       Ocean Essentials Balanced Health-Omega 3
       Milk Thistle & Dandelion
       Hair, Skin & Nails (in Women's Supplement Pack)
Poor Focus, Clarity & Concentration
       Ocean Essentials Balanced Health-Omega 3
       Siberian Energy
       Rhodiola 110
Weakened Immune System
       Intestiflora
       Kiwi-Strawberry Immunity Twist Tubes
       Echinacea Liquid, Spray or Tablets
Anemia
       Tri-Iron Folic Acid
Having Trouble Sleeping
       Valerian & Hops
       Cal Mag D
Low Energy/Fatigue
       Nutrilite Women's or Men's Supplement Pack
       Siberian Energy
       XS Energy Drinks
       Tri-Iron Folic Acid
       Rhodiola 110

Question 3

Approximately how many servings fo fruits and vegetables do you normally eat each day?
(one serving = 1 medium fruit, 1 cup raw vegetables, 1 cup cooked vegetables, or 1 cup juices)
       0
       1 to 2 servings
       3 to 4 servings
       5 or more servings

There is only one thing the American Cancer Association has ever stated that prevents cancer and chronic disease: 5 to 9 Servings of Fruits & Vegetables per day.
       Concentrated Fruits & Vegetables
       Blueberry Antioxident Twist-Tubes

Question 4

Do you or your family have a history of cancer?
       Yes
       No

There is only one thing the American Cancer Association has ever stated that prevents cancer and chronic disease: 5 to 9 Servings of Fruits & Vegetables per day.
       Concentrated Fruits & Vegetables
       Blueberry Antioxident Twist-Tubes

Question 5

Do any of the following apply?
       I am in my child-bearing years
       I am in a pregnant or nursing

       Tri-Iron Folic Acid

Question 6

Are you interested in losing weight?
       Yes
       No

       Slimmetry Dietary Supplement
       Carb Blocker 2
       XS Energy Drinks
       Nutrilite 100 Calorie Snack Bars

Question 7

Are you trying to gain muscle mass?
       Yes
       No

       Nutrilite Protein Powder
       Nutrilite Protein Shake
       Nutrilite Protein Bar
       CLA 500 Supplement
       Tropical Hydration Twist-Tubes

Question 8

Are you interested in nutrition for your children?
       Yes
       No

       Kid's MultiTarts
       Kid's Brainiums
       Kid's Chewable Fruits & Vegetables
       Kid's Natural C Chewables
       Echinacea Liquid






Wellness Tips:

These simple movements or daily routines can end up hurting you if you're not careful. Make sure to do these simple activities the right way as outlined below:

Standing

Posture. Posture. Posture. Make sure that you keep your chin up and don't slouch. If you know that you are going to be standing for a long period of time, make sure that you wear comfortable shoes.

Working at a Desk

Make sure that you are getting up every 20 minutes to stretch. The type of chair you have is extremely important. It should fit you correctly so that your back touches the chair and your feet are on the floor with knees at a 90 degree angle. Try to avoid looking down at your computer screen. It should be at eye level.

Sitting

Make sure you have a chair that is supportive. When you are forced to sit for a long period of time, for instance at a desk job, make sure to get up and stretch every 20 minutes. Sit with your back against the chair, feet firmly on the floor. Do not cross your legs.

Lifting

Lifting objects is one of the most common ways to injure yourself. Even if it is a light object, twisting or pulling in the wrong direction when you're not stretched out can have a damaging effect on muscles and the spine. You always want to bend at the knees and avoid lifting anything you know is too heavy.

Overall Physical Activity

If you know that you are going to be working or playing for a while, make sure that you are adequately stretched out and warmed up. Even if it's something light like gardening or just pushing your child on a bike, it's easy to pull something if you're not warmed up.

Talking On The Telephone

If you're forced to use the telephone for a long period of time, a speaker or a headset is a must. By all means try to avoid cradling the phone between your neck and your shoulder as this could cause you to damage the muscles or vertebrae in that area.

Resting or Sleeping

Straining your neck or back while you're sleeping is a very common occurrence. We often fall asleep in strange positions where we are not supported properly or our necks are at an odd angle. Make sure that if you are going to nap or watch tv in bed, that you are in a supportive position.