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CONFIDENTIAL QUESTIONNAIRE

Find Your Weakest link Fast

Give yourself the Most Important Support and Supplements you are missing....

Complete our interactive online questionnaire and receive our free personalized recommendations based on your Weakest links.

To compare your Health results before and after our suggested support, print any or all 3 of your FREE Nutritional Assessment Forms and save them and see the difference in your health!

4 EASY STEPS

Step 1:	Fill out and Submit the form.
Step 2:	Your results are reviewed by our doctor; we will provide you with a personalized nutritional protocol.
Step 3:	We contact you with your results during our regular business hours.
Step 4:	Your order of the correct vitamins to support your weakest link will be Free shipping to you!
Optional
Step 5:	Retake the test and see the improvements and continue improving

Fill out the forms now and start your FREE test for better health!

*Your privacy is of the utmost importance and none of the information we collect is never sold or shared with others. When you fill out the questions and send it to us, we must ask you for certain personal information so that we can provide your personalized results. We will use your email address to communicate any specials and other information designed to improve your experience and save out time and money with the Myvits.com site. At any time, you may unsubscribe by following the "unsubscribe" link in any such email, or by sending us an email request to remove your name from the list. The personal details collected during the evaluation process will not be shared or used in any other way.

CONFIDENTIAL

Health Questionnaire (NTAF)

Name		Date		Sex		Age
*Email

Please check the appropriate number “0-3” on all questions below. 0 as the least/never to 3 as the most/always.

SECTION A

Is your memory noticeably declining?
Are you having a hard time remembering names and phone numbers?
Is your ability to focus noticeably declining?
Has it become harder for you to learn things?
How often do you have a hard time remembering your appointments?
Is your temperament getting worse in general?
Are you losing your attention span endurance?
How often do you find yourself down or sad?
How often do you fatigue when driving compared to the past?
How often do you fatigue when reading compared to the past?
How often do you walk into rooms and forget why?
How often do you pick up your cell phone and forget why?

SECTION B

How is your stress level?
How often do you feel that you have something that must be done?
Do you feel you never have time for yourself?
How often do you feel you are not getting enough sleep or rest?
Do you find it difficulty to get regular exercise ?
Do you feel uncared for by the people in your life?
Do you feel you are not accomplishing your life’s purpose?
Is sharing your problems with someone difficult for you?

SECTION C-1

How often do you get irritable, shaky, or have lightheadedness between meals?
How often do you feel energized after eating?
How often do you have difficulty eating large meals in the morning?
How often does your energy level drop in the afternoon?
How often do crave sugar and sweet in the afternoon?
How often do you wake up in the middle of the night?
How often do you have difficulty concentrating before eating?
How often do you depend on coffee to keep yourself going?
How often do you feel agitated ,easily upset, and nervous between meals?

SECTION C-2

Do you get fatigued after meals?
Do you crave sugar and sweets after meals?
Do you feel you need stimulants such as coffee after meals?
Do you have difficulty losing weight?
How much larger your waist girth compared to your hip girth?
How often do you urinate?
Have your thirst and appetite been increased?
Do you have weight gain when under stress?
Do you have difficulty falling asleep?

SECTION 1-S

Are you losing your pleasure in hobbies and interest?
How often do you feel overwhelmed with ideas to manage?
How often do you have feelings of inner rage (anger)?
How often do you have feeling of paranoia?
How often do feel sad or down for no reason?
How often do you feel like you are not enjoying life?
How often do you feel you lack artistic appreciation?
How often do you feel depressed in overcast weather?
How much are you losing your enthusiasm for your favorite activities?
How much are you losing your enjoyment of friendship and relationship?
How often do you have difficulty falling of dependency on other?
How often do you feel more susceptible to pain?
How often do you have feeling of unprovoked anger?
How much are you losing interest in life?

SECTION 2-D

How often do you have feelings of hopelessness?
How often do you have self-destructive thoughts?
How often do you have an inability to handle stress?
How often do you have anger and aggression while under stress?
How often do you feel you are not rested even after long hours of sleep?
How often do you prefer to isolate yourself from others?
How often do you have unexplained lack of concern for family and friends?
How easily are you distracted from your tasks?
How often do you have an inability to finish tasks?
How often do you feel the need to consume caffeine to stay alert?
How often do you feel your libido has been decreased?
How often do you lose your temper for minor reasons?
How often do you have feelings of worthlessness?

SECTION 3-G

How often do you feel anxious or panic for no reason?
How often do you have feelings of dread or impending doom?
How often do you have feelings of being overwhelmed for no reason?
How often do you have feelings of guilt about everyday decisions?
How often does your mind feel restless?
How difficult is it to turn your mind off when you want to relax?
How often do you worry about things you were not worried about before?
How often do you have feelings of inner tension and inner excitability?

SECTION 4-ACH

Do you feel your visual memory (shapes & images) is decreased?
Do you feel your verbal memory is decreased?
Do you have memory lapses?
Has your creativity been decreased?
Has your comprehension been diminished?
Do you have difficulty calculating numbers?
Do you have difficulty recognizing objects & faces?
Do you feel like your opinion about yourself has changed?
Are you experiencing excessive urination?
Do you feel like your opinion about yourself has changed?

Optional Medication History

Please list any natural supplements you currently take and for what conditions:

Acetylcholine Receptor Antagonist ? Antimuscarinic Agents	if yes, describe
(Atropine, Ipratopium, Scopolamine, Tiotropium)
Acetylcholine Receptor Antagonist - Ganlionic Blockers	if yes, describe
(Mecamylamine, Hexamethonium, Nicotine (high doses), Trimethaphan)
Acetylcholinesterase Reactivators	if yes, describe
(Pralidoxime)
Acetylcholine Receptor Antagonist - Neuromuscular Blockers	if yes, describe
(Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Uccinylcholine, Tubocurarine, Vecuronium, Hemicholine)
Agonist Modulator of GABA Receptor (benzodiazepines)	if yes, describe
(Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valium, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum, Megadon, Serax , Restoril, Halcion)
Cholinesterase Inhibitors (irreversible)	if yes, describe
(Echotiophate, Isofl urophate, Organophosphate Insecticides, Organophosphate-containing nerve agents)
Cholinesterase Inhibitors (reversible)	if yes, describe
(Donepezil, Galatamine, Rivastigmine, Tacrine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine, Carbamate Insecticidses)
Dopamine Reuptake Inhibitors	if yes, describe
(Wellbutrin (Bupropion))
Dopamine Receptor Agonists	if yes, describe
(Mirapex, Sifrol, Requip)
D2 Dopamine Receptor Blockers (antipsychotics)	if yes, describe
(Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, luanxol, Clopixol, Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis, Seroquel, Geodon, Solian, Invega, Abilify)
GABA Antagonist Competitive binder	if yes, describe
(Flumazenil)
Monoamine Oxidase Inhibitor (MAOI)	if yes, describe
(Marplan, Aurorix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Rivivol, Popilniazida, Zyvox, Zyvoxid)
Noradrenergic and Specific Sertonergic Antidepressants (NaSSaa)	if yes, describe
(Remeron, Zispin, Avanza, Norset, Remergil, Axit)
Selective Serotonin Reuptake Inhibitor	if yes, describe
(Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil , Emocal, Serpam, Seropram, Cipralex, Esteria, Fontex, Seromex, Seronil, Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat, Lustral, Serlain, Dapoxetine)
Selective Serotonin Reuptake Enhancers	if yes, describe
(Stablon, Coaxil, Tatinol)
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)	if yes, describe
(Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine)
Tricylic Antidepresseants (TCAs)	if yes, describe
(Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden, Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil, Rhotrimine, Surmontil)

The information contained here should not be construed as a claim or representation than any product or result constitutes a specific cure, palliative or ameliorative. Any products used from myvits should be considered as adjunctive therapy to other accepted procedures, deemed necessary by the attending, licensed doctor of your own choosing.

Vitamins listed in your evaluation are not intended to be used as a treatment or diagnosis of any disease or condition. All support is intended for nutritional purposes only. For treating any medical conditions, use appropriate drug intervention by a physician.

It is the concern of the Department of Health and Human Services that no homeopathic and /or nutritional supplements be used to replace established, conventional medical approaches; especially in cases of emergencies, serious or life threatening diseases or conditions. Myvits shares in this concern, as replacing conventional treatments with such products, especially in serious cases, may deprive you of necessary treatment and thereby cause harm which could be prevented if proper treatment was given. Do not use any of these formulas of nutritional products as replacements for conventional medical treatment.

The information you are receiving has not been evaluated by the Food and Drug Administration. The products mentioned on myvits.com and these results are not intended to diagnosis, treat, cure, or prevent disease.

The information you are receiving is solely the opinion of myvits.com. It is not to be construed or intended as providing medical or legal advice.

The information is not intended to be a substitute for personalized medical attention and advice.

This information is not necessarily considered mainstream medicine. It is left to the discretion and is the sole responsibility of the user of this information indicated on this website and questionnaire to determine if any nutritional therapy described is appropriate for you.