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Ingredients
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What's your first name?
What's your first name?
Gender
Gender (at birth)
Male
Female
Age
How old are you?
BMI - Height
How tall are you?
Feet:
0
3
4
5
6
7
Inches:
0
1
2
3
4
5
6
7
8
9
10
11
BMI - Weight
Weight (lbs):
ISQ - Intro
In this next set of questions, please indicate how often you have had the following complaints
in the past year
:
ISQ - 1
Sudden high fever:
Never
Sometimes
Regularly
Often
(Almost) Always
ISQ - 2
Diarrhea:
Never
Sometimes
Regularly
Often
(Almost) Always
ISQ - 3
Headache:
Never
Sometimes
Regularly
Often
(Almost) Always
ISQ - 4
Skin problems (e.g. acne & eczema):
Never
Sometimes
Regularly
Often
(Almost) Always
ISQ - 5
Muscle and joint pain:
Never
Sometimes
Regularly
Often
(Almost) Always
ISQ - 6
Common cold:
Never
Sometimes
Regularly
Often
(Almost) Always
ISQ - 7
Coughing:
Never
Sometimes
Regularly
Often
(Almost) Always
GENERAL - Do you often feel tired and exhausted and/or have fatigue not helped by rest?
In the past year...
Have you felt tired and exhausted and/or have had fatigue not helped by rest?
Yes
Sometimes
No
GENERAL - Do you regularly experience gas, bloating, and/or tummy trouble?
In the past year...
Have experienced gas, bloating, and/or tummy trouble?
Yes
Sometimes
No
GENERAL - Do you have regular bowel movements? (No more than 3 times per day and no less than once every 3 days)
In the past year...
Have you had regular bowel movements?
(No more than 3 times per day and no less than once every 3 days)
Yes
Sometimes
No
GENERAL - Do you exercise at least 30 minutes a day, 5 days per week?
In the past year...
Have you exercised at least 30 minutes a day, 5 days per week?
Yes
Sometimes
No
GENERAL - Do you spend at least one hour per day outdoors?
In the past year...
Have you spent at least one hour per day outdoors?
Yes
Sometimes
No
GENERAL - Do you tend to have dry skin and cracked lips?
In the past year...
Have you often had dry skin and cracked lips?
Yes
Sometimes
No
GENERAL - Do you have trouble sleeping and/or suffer from insomnia?
In the past year...
Have you had trouble falling/staying asleep at night and/or suffer from insomnia?
Yes
Sometimes
No
GENERAL - Do you have close contact with many people on a regular basis outside of household family members?
In the past year...
Have you had close contact with many people on a regular basis outside of household family members?
Yes
Sometimes
No
GENERAL - Are you often exposed to stressful situations?
In the past year...
Have you often been exposed to stressful situations?
Yes
Sometimes
No
GENERAL - Do you eat at least 8 servings of fruit and vegetables per day (a serving is ½ cup)?
In the past year...
Have you eaten at least 8 servings of fruit and vegetables per day (a serving is ½ cup)?
Yes
Sometimes
No
GENERAL - Do you smoke?
Do you smoke?
Yes
Sometimes
No
GENERAL - Do you experience headaches and/or nausea when exposed to environmental chemicals, perfumes, and/or prescription drugs?
Do you experience headaches and/or nausea when exposed to environmental chemicals, perfumes, and/or prescription drugs?
Yes
Sometimes
No
SECTION 2 - Intro
In this final set of questions, please indicate in what ways you typically experience colds and flu or how you respond to infection:
SECTION 2 - Sore throat:
Sore throat:
Yes
Sometimes
No
SECTION 2 - Stuffy nose or sinuses:
Stuffy nose or sinuses:
Yes
Sometimes
No
SECTION 2 - Swollen lymph nodes:
Swollen lymph nodes:
Yes
Sometimes
No
SECTION 2 - Ear infection:
Ear infection:
Yes
Sometimes
No
SECTION 2 - Stomach aches:
Stomach aches:
Yes
Sometimes
No
Last page 1
Congratulations!
You have now completed the
my
mmunity questionnaire and are about to see your recommended personalized immune health formula
Last page 2
Remember, you can
ADD
or
REMOVE
ingredients to suit your needs
and
All ingredients in your
my
mmunity formula will be blended together and placed into custom capsules, just for
YOU!
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