Welcome to your Pill Advisor What is your name? Our questionnaire is based on biological/birth sex instead of identity to ensure your safety during supplement recommendations What's your biological gender? Male Female How old are you? Teens Twenties Thirties Forties Fifties Sixties or over How much do you weigh? Less than 100 lbs. 101 to 150 lbs. 151 to 200 lbs. 201 to 250 lbs. 251 to 300 lbs. 301 lbs. or more How tall are you? Less than 4 feet 4 to 5 feet 5 to 6 feet 6 to 7 feet 7 to 8 feet Do you currently take vitamins or supplements? Yes No 1 out of 15 What are your goals for taking supplements? My general health and wellness I’m concerned about my immune health I want to improve my athletic performance I’ve had weight loss surgery What are your top 3 health concerns? Immunity Fitness Digestion Mood Heart Sleep Joints Hair, Skin, and Nails Stress Energy Endocrine System 2 out of 15 We would like to base our recommendations to your dietary preferences Do you follow any of these special diets? Paleo Ketogenic Vegetarian Vegan Pescatarian Other Do you have any of the following food allergies? Peanuts Eggs Shellfish Dairy Wheat Soy Lactose Like a medium apple, a banana, or ½ cup berries. On average, how many servings of fresh fruit do you eat in a day? None to 2 servings 3 to 5 servings 6 or more Like ½ cup cooked vegetables or one cup raw vegetables. On average, how many servings of fresh vegetables do you eat in a day? None to 2 servings 3 to 5 servings 6 or more Like milk, yogurt, and cheese. How many servings of calcium-rich foods do you typically eat in a day? None to 2 servings 3 servings 4 or more Like salmon, sardines, or anchovies. How many servings of fish, rich in Omega-3 fatty acids, do you eat in a week? None to 1 servings 2 to 3 servings 4 or more How many servings of high fiber foods do you eat a day? How many servings of high fiber foods do you eat a day? None to 1 servings 2 to 3 servings 4 or more How many days a week do you drink alcoholic beverages? None or rarely 1 or 2 days per week 3 or more days per week 3 out of 15 Do you get limited sun exposure or use sunscreen daily? Yes No Do you exercise regularly? Never or rarely Maybe once week 2 or 3 times a week 4 or more times a week I’m a professional athlete 4 out of 15 How's your mood and stress levels? I have no complaints I am rarely happy I’ve recently experienced a stressful event (e.g. loss of job, divorce) I’d like to improve my mood I’m stressed all of the time I often feel fatigued and unable to focus On average, how well do you sleep? I sleep well I don’t sleep well My sleep is interrupted (snoring or waking up to urinate) When I try to sleep my mind often races. 5 out of 15 Do you have any of these conditions related to your eye, nose and gum health? Glaucoma Sinusitis Gingivitis Macular Degeneration Cataracts None 6 out of 15 Do you have any of these conditions related to your lung health? Emphysema Asthma Exercise Induced Asthma Chronic Obstructive Pulmonary Disease (COPD) Another lung condition None 7 out of 15 Do you have any of these conditions related to your heart health? High Triglycerides Congestive Heart Failure Atherosclerosis High Blood Pressure High Cholesterol Angina Calcium Channel Blockers. None 8 out of 15 Do you have any of these conditions related to your joint and bone health? Osteoporosis Rheumatoid Arthritis Osteoarthritis Tendinitis None 9 out of 15 Do you have any conditions related to your stomach and digestive health? Abdominal Pain Irritable Bowel Syndrome Acid Reflux or Heartburn Indigestion None 10 out of 15 Do you have any conditions related to your kidney and bladder health? Frequent Bladder Infections History of Kidney Stones None Do you have any conditions related to blood sugar and endocrine health? Type I Diabetes High HbA1c/Prediabetes Generally high blood sugar levels, no diabetes diagnosis Diabetic Neuropathy Hyperthyroidism Diabetic Retinopathy Type II Diabetes Hypothyroidism None 11 out of 15 Do you have any of these conditions related to your immune or cellular health? Hashimoto’s Thyroiditis Autoimmune Thyroid Diseases (TITD) I have had or currently have cancer Frequent colds or viral infections Celiac Disease Chronic Fatigue Syndrome Seasonal allergies Lupus None 12 out of 15 Do you have any of these conditions related to your nervous system? I have restless leg syndrome preventing me from sleeping well Vertigo Alzheimer’s diagnosis Fibromyalgia Age-related cognitive decline None 13 out of 15 Do you suffer from any of the following? PMS Symptoms related to menopause Frequent UTIs No Do you have an enlarged prostate? Yes No Do you are any one in your immediate family had any of these conditions? Colon Cancer Prostate Cancer No 14 out of 15 Are you taking any of the following types of medication? Acid-Suppressing Drugs And Antacids Ex: Nexium®, Pepcid®, Prevacid®, Prilosec®, Tagamet® Antibiotics Ex: Amoxil®, Bactrim®, Ceclor®, Cipro®, Levaquin® Antidepressants Ex: Cymbalta®, Lexapro®, Paxil®, Prozac®, Zoloft® Antiepileptics (Anticonvulsants) Ex: Dilantin®, Lyrica®, Mysoline®, Tegertol®, Trileptal® Antipsychotics Ex: Abilify®, Haldol®, Seroquel®, Risperdal®, Zyprexa® Atrial Fibrillation (Afib) Birth Control (Oral Contraceptives) Migraine Headaches Blood Pressure (Anti-Hypertensives) Ex: Ace Inhibitors, Angiotensin Receptor Blockers (Arbs), Beta Blockers Blood Thinning (Anticoagulants/Antiplatelets) Ex: Aspirin, Coumadin® (Warfarin), Plavix®, Ticlid®” Cholesterol Lowering (Statins) Ex: Crestor®, Lescol®, Lipitor®, Mevacor®, Zocor® Corticosteroids Ex: Prednisone Diabetes Medication (Oral Hypoglycemics) Ex: Avandia®, Diabeta®, Glucophage® (Metformin), Prandin® Digioxin Ex: Cardoxin®, Digitek®, Lanoxicaps®, Lanoxin® Diuretics Ex: Aldactone®, Diamox®, Lasix®, Microzide® (Hctz), Zaroxolyn® Hormone Replacement Therapy (Estrogens) Ex: Estrace®, Premarin®, Prempro®, Compounded Hormone Replacement Medication Anxiety (Benzodiazepines) Ex: Ativan®, Prosom®, Restoril® Valium®, Xanax® Other No 15 out of 15 Time is Up! Time’s up
