Order NumberCongratulations! You've made it to your 90 day progress survey. Please take the time to fill out this questionnaire for your next nutrition visit along with any tests or other food logs. This lets us fine tune and make any changes as needed to keep you on top of your health. First Name * Last Name * Email Address * Allergies * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Anxiety / Mood * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Body Weight * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Appetite * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Fatigue * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Energy Level / Activity * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Sleepy Quality * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Joint / Muscle Stiffness * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Gut Discomfort * Worse No Improvement (0% Better) Slightly Better (25% Better) Significantly Improved (50%) Feel Great (No Symptoms, 100% Better) Medication Changes?List present and new medications. Please make note if you have increased or decreased any dosages of present medications. New Tests?Have you had any blood tests or other diagnostic testing performed since your last visit? If yes, what have you done? (Bring to visit) Other Supplements?Are you taking any other supplements or nutritional products other than what has been prescribed to you since your last checkup? If yes what? Challenges? *What has been your greatest challenge in sticking with the program? Feedback *Is there anything that bothers you about our services? (We promise you won't hurt our feelings :) please let us know if there is) New Symptoms, Comments, Questions or Complaints? *
