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Personal Health Assessment


Please fill out the following chart at the beginning of your dietary supplement program.  This is for your personal information only, and designed as a point of reference to look back at after 3, 6 and 12 months of using dietary supplements.

Check off the item(s) appropriate to your current personal health.


1. ____ Low energy
2. ____ Lack of vitality (low endurance level, energy crashes, etc)
3. ____ Skin problems (dry, itchy, acne, rashes, etc)
4. ____ Headaches – how often?
5. ____ Memory lapses – frequency?
6. ____ Aching joints
7. ____ Cramps in muscles
8. ____ PMS, Cramps, Menstrual problems
9. ____ Use pain killers – frequency?
10. ___ High Blood Sugar (Diabetic)
11. ___ Low Blood Sugar (Hyperglycemia)
12. ___ High Blood Pressure (Hypertension)
13. ___ Low Blood Pressure
14. ___ Emotional Instability (highs and lows)
15. ___ Handle stress poorly
16. ___ Depression
17. ___ Poor concentration / Lacking in mental clarity
18. ___ High alcohol consumption
19. ___ High coffee consumption
20. ___ Frequent colds & congestion
21. ___ Allergies (pets, food, plants, etc)
22. ___ Poor immune system
23. ___ Difficulty getting up in the morning
24. ___ Difficulty falling asleep
25. ___ Difficulty sleeping throughout the night (Insomnia)
26. ___ Digestive problems (Acid Reflux, Burping, Belching)
27. ___ Heartburn or Acid Indigestion
28. ___ Constipation
29. ___ Bad Breath
30. ___ Cold Hands or Feet
31. ___ Temperature Sensitivity
32. ___ Dry or Brittle Nails
33. ___ Dull, Thinning or Graying Hair
34. ___ Overweight / Underweight (circle one)
35. ___ Craving for Carbohydrates
36. ___ Strong desire for chocolates/sweets
37. ___ Shortness of Breath / Poor Oxygenation
38. ___ High Cholesterol
39. ___ Cuts and Bruises Heal Slowly

Is there anything else you wish to add?



After filling in your personal health assessment (make sure you take a few days to record all challenges – it’s amazing how one forgets the subtle changes over time), please file in a safe place.

Revisit this list and record changes after:

3 months:


6 months:


12 months:


Congratulations!!  Please feel free to share your health benefits and improvements with your health professional and also with the person who introduced you to these dietary supplements.  The mission is to make a difference by introducing people to excellent natural source liquid dietary supplement choices. 

The wellness philosophy is: “when the body gets what it needs, it then has the opportunity to address its health challenges” and good dietary supplement products help to supply those needs!

Congratulations on choosing an enhanced road to wellness for you and your family, and thank you for being a valued customer.

This information is for educational purposes and is neither designed nor intended to diagnose, treat, cure or prevent any disease.


Please click here for a downloadable copy

For more information, or any questions, please email or call 316.684.6597