Questionnaire

A special gift for the people that downloaded the free eBook – 21 Ways to Improve Your Thyroid Health

thyroid-ebook

Fill out the form below to receive your free Nutritional Assessment Report by Nutri-Q. This is a very comprehensive nutritional analysis that will take approximately 20 minutes to complete. This report will identify which organs, glands and/or systems of the body would benefit from some additional nutritional support through dietary modifications and/or whole food supplementation. This report is not intended to diagnose or replace seeking medical attention. It is designed to serve as an educational tool and platform from which conversation with a health practitioner can begin.

Fill out the form below with your information. After we set you up in the system, you will receive an email notification to confirm your account. You will need to click on the confirmation link. Once you’ve been confirmed, you will receive the email to fill out the questionnaire online.

Your Name (required)

Your Email (required)

Your Zip Code (required)

What are your 5 health concerns? (Include at least 3)

Health concern #1 (required)

Health concern #2 (required)

Health concern #3 (required)

Health concern #4

Health concern #5

What is your date of birth? (month, day , year)