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All items MUST be filled out to receive the two FREE samples*
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Your Full Name, please:
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Mailing Street/PO Box Address:
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Your Primary Email:
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City:
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Phone Number with Area Code:
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State or Province:
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Best Time to Call:
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Country:
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Q: I would like to prevent heart disease.
Yes No
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Q: Have you taken supplements before?
Yes No
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Q: If you've taken supplements, what were the results?
Excellent
Good
Fair
Poor
N/A
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Q: I need to lower my cholesterol.
Yes No
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Q: I would like to lose weight.
Yes No
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Q: If yes, please indicate how much weight you'd like to lose:
5-10 lbs
10-20 lbs
20-30 lbs
30+ lbs
N/A
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Q: Do you, or someone in your household, have respiratory problems such as asthma/allergies?
Yes No
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Q: I would like relief from stress.
Yes No
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Q: I am diabetic.
Yes No
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Q: Do you crave carbohydrates and/or sweets?
Yes No
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Q: Do you suffer from joint pain?
Yes No
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Q: Do you have energy drops/low blood sugar?
Yes No
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Q: If yes, please indicate when you experince these energy drops:
Late Morning
Early Afternoon
Late Afternoon
Early Evening
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Q: Do you suffer from frequent colds or the flu?
Yes No
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Q: Are you interested in receiving free information about targeted solutions for women's health, including PMS and menopause solutions?
Yes No
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Q: Are you interested in receiving free information about targeted solutions for digestive health, including lactose intolerance and IBS?
Yes No
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Q: Are you interested in receiving free information about targeted solutions for men's health, including prostate health?
Yes No
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Q: Are you interested in receiving free information about targeted solutions for children's health, including ADD/ADHD?
Yes No
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Q: Are you interested in receiving free information about targeted solutions for a healthy home?
Yes No
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Q: Are you concerned about not being able to obtain purified, healthy water from your tap?
Yes No
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Q: Do you currently spend more than 20 dollars a month on nutritional supplements?
Yes No
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Q: Do you currently spend more than 20 dollars a month on bottled water?
Yes No
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Q: What is your age group?
Under 20
20 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80+
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Q: What is your time zone?
Newfoundland
Atlantic
Eastern
Central
Mountain
Pacific
Alaska
Hawaii-Aleutian
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Q: Have you ever purchased anything online?
Yes No
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Q: I am interested in learning how to:
Supplement my current income
Replace my current income
Make more than my current income
I'm not interested in making money
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