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During the past week I have experienced: (check all that apply)

Stress
Anxiety
Depression
Fatigue



From the above, how often have you experienced these in the past week?
not at all
a little
moderately
quite a bit
extremely

I am interested in finding ways to: (check all that apply)

Boost energy levels and reduce fatigue
Promote vigor through mental and physical stamina
Improve coping abilities while stressed
Enhance mood and a feeling of well-being
Restore concentration and mental alertness
Maintain metabolic balance
Feel cheerful, alert, resilient, vigorous and youthful
A natural way to "feel great"



What age group are you in?
Under 20
20 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 plus
 
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