Health and Wellness Survey

Sheet3 Sheet2 Sheet1 DATE:__________________________________ WEIGHT MANAGEMENT/ LOSS HEART DISEASE DIGESTION/STOMACH DIABETES PROSTATE HYPERTENSION/HIGH BLOOD PRESSURE CANCER: COLON/BREAST CHILDREN'S HEALTH MENOPAUSE: PRE/POST STRESS RELIEF SPORTS NUTRITION SLEEP/RELAXATION ARTHRITIS/JOINT HEALTH ENVIRONMENTALLY-FRIENDLY HOUSEHOLD CLEANERS WATER AND AIR PURIFICATION ASTHMA A. IF I COULD SHOW YOU A WAY TO GET HEALTHIER AND STAY HEALTHY, WOULD YOU BE INTERESTED? YES______ NO______ B. IF I COULD SHOW YOU A WAY TO STAY HEALTHY AND MAKE SOME MONEY, WOULD YOU BE INTERESTED? YES______ N0______ C. HAVE YOU EVER TRIED ANY SHAKLEE PRODUCTS? YES_____ NO______ NAME:___________________________________________________________________________________________________ WHICH OF THE FOLLOWING HEALTH ISSUES CONCERNS YOU? OTHER PHONE:____________________________________________________________ BEST TIME TO CALL AM______ PM____ EMAIL:_________________________________________________________________________________________________________________ CHOLESTEROL REGULATION LOW ENERGY HEALTH AND WELLNESS SURVEY