Quality Food

Health Survey

Every journey has a starting point.

HEALTH SURVEY

Let's start feeling better!

Start your survey here...

Thank you for trying Michelle's Probiotic Cultured Milk! We're excited to be a part of your wellness journey!

This form will be used as a baseline to assist us in determining the benefits that you will hopefully see and feel from using this product. Please complete this as accurately as possible. If you're unsure of the answer or are not comfortable with any part of this questionnaire, please skip it. Your name or contact information will never be used without your consent.

Statement of acceptance by user

First Name *

Last Name *

Email *

Phone *

Date of birth *

Gender *

Female

Male

Have you been diagnosed with a digestive condition or disease? (ie; IBS, Crohn's, Celiac, Diverticulitis) *

Yes

No

If Yes, please describe...

How would you rate your energy levels? *

Excellent

Good

Fair

Poor

Do you suffer from any of the following? Select all that apply *

Mood Swings

Depression

Anxiety

No

Height

Weight

Optional- Please provide any additional information regarding health conditions or concerns.