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A4H Symptom Survey

This intuitive and adaptive symptom survey gives us the ability to learn about your health history and health goals so we can better assist you with product recommendations. We look forward to joining you on your health journey!

General Information

Name(Required)
Today's Date(Required)
DOB(Required)
Address(Required)

Medical Intake

Toxicity and Symptom Screening

Check all boxes that pertain to you
Digestive Tract
Head
Mouth/Throat
Ears
Heart
Nose
Emotions
Joints/Muscles
Skin
Energy/Activity
Lungs
Weight
Eyes
Mind
Other

Disclaimers

I fully understand this is a Symptom Survey designed to provide non-clinical information to a Supplement Specialist(Required)
I fully understand the difference between the practice of allopathic (conventional) medicine, nutritional wellness consulting, and Quantum Cellular Scans(Required)
I fully understand that any reference to "patient" within this therapy is solely due to technical terminology and in no way implies that the client is a medical patient(Required)
The Food and Drug Administration has not evaluated these statements. This Symptom Survey is not intended to diagnose, treat, cure or prevent any disease(Required)
We employ preventative care to maintain peak health, and utilize functional medicine to efficiently treat existing health issues.
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8320 Stone Run Court
Tampa, FL 33615
800-454-1920
info@alive4health.com

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We employ preventative care to maintain peak health, and utilize functional medicine to efficiently treat existing health issues.
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540 Oak Centre Dr Suite 114
San Antonio, TX 78258
800-454-1920
info@alive4health.com

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© 2023 - Alive4Health. **Disclaimer: None of the information presented on our website or blog is intended to service as legal or regulatory counsel. Users are encouraged to seek professional assistance and counsel if they are concerned about a specific legal or regulatory issue. ***These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.