Wellness Health Survey

Home Mission Important Notice Town of Allopath Protocel Video Immune System Video Immune System Test Wellness Health Survey Protocel Prevention Package Wellness Testing Kit pH Package Hair Analysis Picking Supplements Cleansing The Body Wellness Products A-Z WebND Detox Package Protocel Protocel - Doctors Info Renewal Products A-Z Wellness Information Testimonies Return Policy Contact Us This Wellness Health Survey has been designed for those that are entering the WebND Life Extender Program. Anyone can take the survey whether they participate in  the program or not. The results are automatically emailed to a Life Extender at WebND Life Extenders. Please fill in all the blanks.   When you fill this form out and submit it to us, you will recieve through the mail a 2 Night 3 Day Vacation Certificate. It allows you to take a vacation in twenty of the popular vacations spots in the Untied States and Mexico. Click the button below to get additional information.   Name of L.E. or R&W representative if they sent you to fill out this form Your name Address Phone (home) Phone (cell or Business) Email Female Male Your age ? Your height ? Your weight ? What is your occupation ? Have you been diagnosed with anything ? Do you smoke ? If you do, how many packs a day ? Do you want to quit ? Do you drink alcohol ? If so how much do you consume a day ? Do you want to quit ? Do you drink soft drinks ? Are they decafinated ? How many glasses of water do you drink a day ? Pick what type of water ? Spring Filter Distilled Tap How many times do you exercise a week ? How long and how fequent do you exercise ? Can you provide any history of health issues that run in your family ? What percentage of fruit do you eat a day ? 5% 10% 15% 20% 25% 30% 35% 40% What percentage of vegetables do you eat a day ? 0% 5% 10% 15% 20% 25% 30% 35% 40% What percentage of meat do you eat a day? 0% 5% 10% 15% 20% 25% 30% 35% 40% What percentage of dairy products do you have a day ? 0% 5% 10% 15% 20% 25% 30% 35% 40% What percentage of protein non-meat do you eat a day ? 0% 5% 10% 15% 20% 25% 30% 35% 40% What percentage of nuts to you eat a day ? 0% 5% 10% 15% 20% 25% 30% 35% 40% What percentage of grains do you eat a day ? 0% 5% 10% 15% 20% 25% 30% 35% 40% In your Wellness Test Kit, place the results of your Dehydration test here ? In your Wellness Test Kit, place the results of your pH test here ? In your Wellness Test Kit, place the results of your Heavy Metal test here ? In your Wellness Test Kit, place the results of your Candida Yeast test here ? In your Wellness Self Evaluation or WellnessTest Kit, place your immune system Intestinal response ? In your Wellness Self Evaluation or WellnessTest Kit, place your immune system Digestion response ? In your Wellness Self Evaluation or WellnessTest Kit, place your immune system Nervous response ? In your Wellness Self Evaluation or WellnessTest Kit, place your immune system Circulation response ? In your Wellness Self Evaluation or WellnessTest Kit, place your immune system Respiratory response ? In your Wellness Self Evaluation or WellnessTest Kit, place your Immune response ? In your Wellness Self Evaluation or WellnessTest Kit, place your immune system Structure response ? In your Wellness Self Evaluation or WellnessTest Kit, place your immune system Urinary response ? In your Wellness Self Evaluation or WellnessTest Kit, place your immune system Glandular response ? * Enter Auth Code

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