Survey Form The NATURAL HEALTH SOLUTIONS Center 10 6th Street, Bristol, TN 37620 – Phone: (423) 968-1536, (800) 980-1648 Hello, We invite you to fill out this form to let us know what your health issues and goals are. We will respond with an email containing information on how we would approach helping you with your health issues or goals. Sincerely, David Luther, Director. First Name: Last Name: Address: Email Address: Phone Number: City: State: Zip: Please check any of the following conditions that apply to you: NUTRITION RELATED ADD/ADHDAcid RefluxAllergies or AsthmaArthritisJoint problemsDigestionLow energySinus infectionsBlood PressureCirculation/Heart problemsDepressionDiabetesFibromyalgiaWeight managementHigh Sugar intake/cravings Primarily NON-NUTRITION RELATED ADD/ADHDAcid RefluxAllergies or AsthmaArthritisJoint problemsDigestionLow energySinus infectionsBlood PressureCirculation/Heart problemsDepressionDiabetesFibromyalgiaWeight managementHigh Sugar intake/cravings Other (write it in): ALLERGIES ENERGY LEVEL: Please check one of the following: LowFairGoodExcellent If you could change one thing about your health, what would it be? Would you like to receive our free monthly newsletter? Please check: YesNo The Natural Health Solutions Center offers its products and services... Read and understood by: Date: Signature: The Natural Health Solutions Center offers its products and services in an effort to help our clients improve their overall health. We do not offer these products or services as cures for any disease. Our recommendations are not meant as a substitute for advice from your doctor. If you have a serious or potentially serious health problem, please see a doctor. You may wish to use our suggestions in addition to the treatment prescribed by your doctor; if so, it is best to do so with his or her knowledge.
