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Please Begin Here:
First Name:
Last Name:
E-Mail Address:
Age:
Sex:
PLEASE CHECK ANY SYMPTOMS YOU HAVE BELOW
AND ANSWER THE RELATED QUESTIONS:
1. Tired in the morning After lunch After dinner
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
2. Need a nap after work/school/shopping - Under 1 hour Over 1 hour
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
3. Need extra hours of sleep Sleep poorly
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
4. Need to urinate during night - Once More than once
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
5. Weak urinary flow Delayed start Dribbling
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
6. Frequent bowel movements after meals
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
7. Weakness or heaviness in extremities Back
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
8. Poor appetite Poor sense of taste Frequent colds
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
9. Dry mouth Frequent bitter taste in mouth
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
10. Tired vision Weak vocal chords Don't like to talk
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
11. Poor hair condition Losing hair
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
12. Poor concentration Poor memory Nervous
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
13. Moody Upset easily Worry too much
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
14. Slow reaction time Premature signs of aging Poor coordination
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
15. Premature/weak ejaculation (men)
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
16. Difficulty reaching orgasm (women) Can't reach an orgasm
Poor Skin Condition
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
17. If you'd like an herbal dietary supplement for your liver
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
18. If under any kind of tumor treatment and wish to use an herbal dietary supplement
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
19. If you's like an herbal dietary supplement for high glucose
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
20. If you'd like an herbal dietary supplement for high cholesterol High triglycerides
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
21. If you'd like an herbal dietary supplement for rheumatoid arthritic pain
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
22. If you'd like an herbal dietary supplement for upset stomach H. pylori positive
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
23. If you'd like an herbal dietary supplement for blemises (pimples)
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
24. If you'd like an herbal dietary supplement for flu/cold
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
25. If you'd like an herbal dietary supplement for chronic itch
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
26. Any other symptom(s)?
How long have you experienced these symptoms?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?
This questionnaire is not a medical diagnosis, and the above may indicate a more serious condition.
Please consult your doctor.
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