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Are you presently taking any type of nutritional supplements (such as vitamins, minerals, herbs, amino acids, fish oils, etc.?
Please choose... Yes No

If yes, list them below

Who recommended you take these supplements?
family member or friend
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health professional
other (please specify)

Where did you purchase these supplements?
mail-order
nutrition or vitamin shop
pharmacy
healthcare provider
other (please specify)

If this practice offered an advanced, high quality line of supplements, would you consider purchasing them?
Please choose... Yes No

If this practice offered a simple genetic test to determine what supplemental regimen is best for you, based on your genetic variations, would you consider doing it?
Please choose... Yes No

If this practice offered a comprehensive weight management program, would you consider doing it?
Please choose... Yes No

If this practice offered a nutrition education program to improve your health and vitality, would you consider it
             by appointment with one of our staff ?Yes  No
             by a class exclusively for our patients? Yes  No

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