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Nutrition Outreach QUESTIONNAIRE

 Date   _____________________________

 Name ___________________________________________________________Age_______________Weight_______________

 Address___________________________________________________________Zip__________Phone____________________

1. List HEALTH PROBLEMS

 A.________________________________________________B.____________________________________________________

 C.________________________________________________D.___________________________________________________

2. What are your Health Goals?

 A.________________________________________________B.____________________________________________________

 C.________________________________________________D.___________________________________________________

3. Are you on any Medication? Please list name, amount and what they are for.

 A.________________________________________________B.____________________________________________________

 C.________________________________________________D.___________________________________________________

4.What type of Surgery have you had?

 _________________________________________________________________________________________

 _________________________________________________________________________________________

5. Are you currently using Nutrition Outreach or any other Herbal, Nutrition or Vitamin Products? Please List.

 A.________________________________________________B.____________________________________________________

 C.________________________________________________D.___________________________________________________

6. Please check if you suffer from the following.

Tiredness                                                          Skin Problems                              Urinary Tact Problems

Dizziness                                                           Prostate Problems                       Joint Pain

Overweight                                                        Menstrual Problems                     Gout     

Underweight                                                      Menopausal Problems                  Arthritis  

Poor Circulation                                                 Yeast Infections                          Sports Injuries                              

High Blood Pressure                                         Respiratory Problems                   Other ____________________

High Cholesterol                                                Lung Problems                              ________________________

Heart Problems                                                  Liver Disorders                              ________________________

7. Would you like a Suggested NUTRITION OUTREACH SUPPORT PROGRAM?

Yes ____ No ____ I will pay by: Cash ___ Money Order ___ Credit Card____ Check___

8. Would you like to be notified of up and coming SEMINARS?   Yes ____ No ____

How did you hear about NUTRITION OUTREACH? _______________________________________________

                            If you would like a Personal Suggested Nutritional Support Program please write to:

NUTRITION OUTREACH INC. P.O.DRAWER 12279-2279 FORT PIERCE, FL. 34979

E-mail us and we will E-mail you a copy of your requested program and price sheet.  If you wish to have a personalized program E-mail us for a Health Questionnaire, download form listed above and return with $40.00 certified check or money order.

We will develop a special 30 day suggested Renew Your Health Program and return it to you by mail. 

If you wish to include a recent complete blood test with your questionnaire add an additional $60.00 for a total of $100.00.  

Follow up suggestions are FREE after 30 days completion.  

Question and answers are available during the 30 day program by E-mail or telephone. 

Product orders can be obtained by C.O.D., PRE-PAID, VISA or MASTERCARD.

     

NUTRITION OUTREACH  P.O. Drawer 12279-2279 Fort Pierce, FL 34979. 

Information Lines: (772) 466-7707    Order Lines: (800) 222-2510