GetSuperHealthy ~ Health Quiz

This form is designed exclusively for non-Shaklee Members & those directly associated with the Tripp Organization. Members/Distributors with Shaklee (who are enrolled with a sponsor outside of the Tripp Organization) are NOT eligible to participate in The Health Quiz. If you have questions or wish to purchase Shaklee products, please contact your Shaklee Sponsor or Business Leader of record.

This questionnaire is not intended to diagnose, treat, cure, or prevent any disease. It will be used as a guide for your Get Super Healthy Wellness Consultant. The answers you provide will be held in the highest confidentiality. You may choose the option 'I choose not to disclose' for any of the questions listed below. Our goal is to discover how we may best assist you with your wellness program and health goals. Please be assured that we do not and will never sell your information to anyone at any time.

I agree

I do not agree

How did you hear about this questionnaire? Please name the person who referred you: *

Your Contact Information

First Name *

Last Name *

Street Address *

City, State and Zip *

Email Address *

Phone Number *

Date of Birth (mm/dd/yyyy) *

Occupation (optional)

Please double check your e-mail address, this is the one we will use to send you a copy of your answers once you have submitted the form. Thank you.

Your Vitality Score

Rate the following six statements to determine your Vitality Score.

Score of 17 or under = There's no place to go but up, you can do it
Score of 18 to 24 = the good news is that you're doing OK, you're on your way up
Score of 25 to 30 = Bravo! You obviously care about taking care of yourself, keep it up

Daily Energy Level - Rate yourself 1 (lowest) 5 (Highest) *

Immune System Strength - Rate yourself 1 (lowest) 5 (Highest) *

Appearance of skin, hair and nails - Rate yourself 1 (lowest) 5 (Highest) *

Ability to manage stress - Rate yourself 1 (lowest) 5 (Highest) *

Overall Health Outlook - Rate yourself 1 (lowest) 5 (Highest) *

Daily Diet - Rate yourself 1 (lowest) 5 (Highest) *

Please Identify Your Health Challenges

Please check the best option with regard to each of the following items: *

	Often	Occasionally	Never	I choose not to disclose
I suffer from allergies/asthma/sinus infections	Often	Occasionally	Never	I choose not to disclose
I experience stress/anxiety/lack of focus/poor memory	Often	Occasionally	Never	I choose not to disclose
I have osteoarthritis/joint pains/all over aches and pain	Often	Occasionally	Never	I choose not to disclose
I have trouble sleeping and/or waking up	Often	Occasionally	Never	I choose not to disclose
I retain fluids and or have poor circulation	Often	Occasionally	Never	I choose not to disclose
I have problems with constipation (not having bowel movements daily)	Often	Occasionally	Never	I choose not to disclose
I have Crohn’s/colitis/IBS (irritable bowel syndrome)	Often	Occasionally	Never	I choose not to disclose
I experience acid indigestion/gas/bloating	Often	Occasionally	Never	I choose not to disclose

Status of Blood Pressure ~ Cholesterol ~ Blood Sugar

Please identify any of the following applicable health challenges *

	Yes	No	On medication	Choose not to disclose
I have high blood pressure	Yes	No	On medication	Choose not to disclose
I have high cholesterol	Yes	No	On medication	Choose not to disclose
I have high blood sugar	Yes	No	On medication	Choose not to disclose

About my weight *

I would like to lose 5 to 15 lbs	I would like to lose 20 - 50 lbs
I would like to lose over 50 lbs	I'm on a weight loss program now
I've been on weight loss plans in the past	I need to gain some weight
I'm at a healthy weight	I choose not to disclose

List 3 major concerns you'd like to prevent or may already have addressed *

The quantity of water you drink daily *

	None	1 to 3	4 to 8	8 or more
How many glasses a day do you drink	None	1 to 3	4 to 8	8 or more

I eat 4 to 7 different fresh fruits and 4 to 7 different vegetables as part of my daily diet *

7 days a week

4 to 6 days a week

1 to 3 days a week

I rarely eat fresh fruit & vegetables

What have you eaten in the past 72 hours? *

List all vitamins/minerals you're currently taking and why you take them, If too many to list, please name the top three and let us know how many you take all together. *

List all medications you are currently taking and why you take them. If there are too many to list, please name the top three and tell us how many you take total *

How much per month, on average, do you currently spend on vitamins, meal bars, snack bars, sports drinks, energy drinks, random snacks and protein shakes? *

How much per month, on average, do you spend on Doctor visits and/or medications. Include prescription and/or OTC medications *

Please rank the following 1 thru 7 according to what is important to you when choosing products for your health and the health of your family. 1 being top priority and 7 being your least important *

	A company that performs clinical studies on ingredients or products
	Lowest price
	No artificial colors, flavors, sweeteners or preservatives
	Feel better or 100% money back guarantee
	A company that focuses on safety and quality
	The company does no animal testing
	Convenience

Please tell us about your fitness activities (walk, run, weights, yoga, dance, swim etc) How often do you do it and for how long do you train each time *

Please give us a short description of your health goals *

Comments and/or questions

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C & A Tripp Associates ~ candatripp@earthlink.net ~ 512.248.1433

Any person who suspects they have a medical problem or disease should consult their physicians for guidance and proper treatment.The information here is provided for educational or general informational purposes only, which is implicitly not to be construed as medical advice. No claims, guarantees, warranties or assurances are implied or promised. We do not intend to diagnose, prescribe, or treat any disease, illness or injury, or in any way substitute for medical advice.The authors and distributors of the enclosed information will not be held responsible for any misconceptions or misuse of the information presented herein.

$0	$10 - $50
$51 - $100	$101 - $150
$151 - $200	Over $200
I choose not to disclose

$0	$10 - $50
$51 - $100	$101 - $150
$151 - $200	Over $200
I choose not to disclose