Vitamin & Supplement Quiz

New Patient/Restart Patient: *

Yes

No

Name:

What diet are you following?

Select your Gender (Optional):

Male

Female

Other

Select an illnesses you may have:

Select one of the following symptoms you may be experiencing:

Do you have any of the following health concerns?

Do any of these life circumstances apply?

Select the most important goal that applies to you:

Gender Associated (Male):

Gender Associated (Female):

MD Diet (High Protein)	Ketogenic Diet	Keto Transition Program
Lifestyle or Maintenance Program	Plant-Based Diet	None of the above

Digestive Discomfort	High Stress	Difficulty Sleeping
Low Quality Sleep	Poor Immune System	Low Energy
Slow Metabolism	Hair Loss, Brittle Nails or Dull Skin	Weakness or Fatigue
Constipation	Severe Food Cravings	Inflamation
Water Retention	Difficulty losing weight	Brain Fog or Difficulty Focusing
Cramping	Sore or painful joints	Poor Circulation
Restlessness (irritability)	None of the above

Low Bone Density	Lactose Intollerance	Gluten Intollerance
High Pain Sensistivity	Dry Mouth	Allergies
Headaches/Migraines	Gastro Intestinal Issues	Increased Risk of Blood Clots
Dizziness or Nausia	None of the above

Graveyard Shift Work	High Stress Circumstances	Recovering from Surgery or major Injury
Highly Active or Labor Intense Job	Intense Daily Exercise	Degenerating Vision
None of the above

Improve Strength or Grow Muscle	Increase Thickness or Strength of Hair or Nails
Metabolize Fat Better	Decrease inches around your waist
Improve Energy	Get Better Quality of Sleep
Reduce Acne	Increase recovery time
Slow the aging process	Strengthen tooth enamal
Improve nerves and mobility	Increase endurance
Improve Regularity (Bowel Frequency)	None of the above

Improve Verility & Lebido	Increase Testosterone	Prostate Health
Sperm Count/Fertility	None of the above