Learn How You Can Use Natural Supplements to Support You. Take my       "Nutritional Stress Survey" Answer these questions, hit submit and I will personally review and e-mail you my nutritional suggestions

Your Information *

Enter First Name * Your E-mail address (enter carefully) *

I am a:

Male Female

My age is:

Under 25 25 - 40 41- 55 55 +

Which best describes your current weight:

Very underweight. I look emaciated Underweight and need to gain a few pounds Ideal weight A few extra pounds Very overweight More info

How often do you find yourself ill with a cold or flu?

Less than 1 time per year 1-3 times per year 4-6 times per year 7 to 10 times a year Seems like I go from one illness to another More info:

Please check any digestive symptoms that you may have:

Bloating Moderate Gas (flatulence) Excessive Gas (flatulence) Feels like food sits in stomach and does not move Occasional Constipation Chronic Constipation Occasional Diarrhea Chronic Diarrhea Other

Check the button that most accurately describes your overall energy levels

High energy almost all of the time High energy levels some of the time Moderate energy levels most of the time Low energy levels some of the time Low energy levels all of the time. Exhausted More Info

If you experience slumps in energy, check off all that apply

Wake up un refreshed. Feel very tired in the AM I need coffee, sodas, cigarettes to get started in the morning. I get slumps of energy around 10 AM and 3 PM I get slumps of energy after meals I need coffee, sodas or candy to keep me alert and functioning More info

Check the button that most accurately describes your childhood living conditions.

Very pleasant. Functional family A little dysfunctional Moderately dysfunctional Stronly dysfunctional. Chaotic More Info

Please check any boxes that apply to you. Feel free to add any additional information in the text box.

As the evening goes on I feel more energetic, and by bedtime, I am wide awake I get tired around 10 - 11 PM, but if I keep pushing, I get a "second wind" and can keep going until 1-2 AM I feel better after dinner I get dizzy if I stand up to quickly More Info

How would you describe your current stress levels

Low Moderate Medium High Very High More Info

Please describe your physical responses to stress. (check all that apply and feel free to add more info in the text box)

I start to tremble or shake I perspire I feel by heart pounding My breathing rate goes up I get a stomach ache I get diarrhea More Info

Please describe your emotional responses to stress (check all that apply and feel free to add additional informtion in the text box)

I feel anxious I feel fear I get angry and hold it in I get angry and let it out at others I feel down or depressed My mind becomes filled with worry and busy thoughts More Info

Please describe how stress is impacting your ability to think or perform in school or your work.

I'm fortunate. My current stress levels do not impact me in this way. Stress is having a mild impact on my school or career, but I'm doing OK Stress is having a moderate impact on my school or work Stress is having a fairly significant impact on school or work. Stress is having a severe impact on my school or work. More info

How many hours of sound sleep do you usually get per night?

Less than 2 hours 2 to 4 hours 4 to 6 hours 6 to 8 hours More than 8 hours

About how long does it typically take to fall asleep?

Less than 10 Minutes 10 to 20 Minutes 20 to 45 Minutes 45 to 90 Minutes More than 90 Minutes More info

Please check all that apply to your sleeping

After falling asleep I sleep soundly After falling asleep I wake up 1-2 hours later, feeling wide awake and unable to go back to sleep After falling asleep, I wake up frequently, but am able to go back to sleep It feels as though I am never in a deep sleep More info

Please List any nutritional supplementation you are now using if any

Any other information you would like to add, or any questions you may have?

Please Read and Press button if you agree to these terms and then press submit *

I understand that this survey and my answers is not designed to diagnose any physical or mental disease and the information I will receive will be educational and informational and not a treatment for any illness. Any decision to use nutritional products is my own and I hold Robert Miller and Gilead Enterprises harmless for my decisions to use nutritional supplements. I agree to these terms