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Wellness Dynamics - Uniquely You Wellness Survey
In order to relate your personality type to possible health problems, complete the following survey. This is an anonymous questionnaire. You don't have to give us your name and address or phone number. All we need is your email address to send you a copy of your personality profile. Be honest and accurate with your answers so we can collect enough statistical data to formulate valuable scientific research. We are asking people to help with this short wellness survey to see how different personalities and behavior relate to specific health problems, and what products and life-style changes may help. Please respond accurately!
You must first complete your Wellness Survey before your Personality Profile questionnaire. You will only be able to have one FREE Personality Profile every 3 months, but must first complete the Wellness Survey again to see if there has been any changes. If you would like to complete another Personality Profile without waiting 3 months, go to www.uniquelyyou.net to complete another profile starting at only $7.50 each.(Couples, Parents or Child.)
Name
First
Last
Email
*
Gender
*
Choose One
Male
Female
Age
*
Choose one
Under 17
18 to 21
22 to 29
30 to 39
40 to 49
50 to 59
60 to 79
80 to 89
90 +
Marital Status
*
Choose one
Single
Married
Divorced
Widowed
Height
*
Choose one
4' to 4'11"
5' to 5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"+
Weight
*
Choose one
Less than 79
80 to 99
100 to 109
110 to 119
120 to 129
130 to 139
140 to 149
150 to 159
160 to 169
170 to 179
180 to 189
190 to 199
200 to 219
220 to 239
240 to 259
260 to 279
280 to 299
300 to 329
330 to 359
360 to 399
400 to 449
450 to 499
500+
Race
*
Choose one
Caucasian
Hispanic
African American
Asian
Other
Education
*
Choose one
Elementary
Jr. Middle School
High School
Diploma
Some College
College Graduate
Some Graduate School
Completed Graduate School
Doctoral Degree
General Health
*
Choose one
Excellent
Good
Average
Not so good
Strength Exercising
*
Choose one
Regularly 3 to 5 times a week
Off/on once or twice a week
None
Nutrition
*
Choose one
Vegetarian
Not Vegetarian but careful with what I eat
Not serious about what I eat
Eat almost anything
Vitamins/ Supplements (Brands used)
*
Choose one
None
Shaklee
NutriLife
Herbalife
Juice Plus
Other
Vitamins/ Supplements (How often used)
*
None
Nearly Every day
Two Time per week
Once or twice per week
Hardly ever or never
Vitamins/ Supplements specific one currently taking
Choose all that apply
All
None
Alfalfa
Cat-Mag
CoQHeart
Essential
Garlic
Herb Lax (Digestive)
Joint Health
Memory Optimizer
Multivitamin
Physique Workout Maximum
B-Complex
Caratomax
CorEnergy
Omega 3 Complex
Gentle Sleep Complex (Valerian)
Iron
Zinc
Mental Acuity
Optiflora Probiotic
Saw Palmetto
Cor Energy
Caratomax
C
Cholesterol Regulation
Defend Resist
EZ Gest
GLA
Immune Building Complex
Lecithin
Menopause Balance Complex
Pain Relief Complex
Soy Protein
Calcium
Soothing Complex
E
Fiber
Glucose Regulation Complex
Instant Protein
Liver DTX
Moodlift Complete
Performance Sports Drinks
Stomach
Have you been diagnosed with?
Check all that apply
All
None
Heart Disease
Cancer
Hypertension/ High Blood Pressure
ADD
ADHD
Arthritis
Aids (HIV)
Blood Pressure
*
Choose one
Don't know
Great
Good
Average
Poor
Very Bad
Cholesterol
*
Choose one
Don't know
Great
Good
Average
Poor
Very Bad
Cardio- Do you have or had heart problems in past?
*
Choose one
Don't have now
Yes, now have
Yes had in past
no, never had
Digestive- Do you have or had digestive problems in past?
*
Choose one
Don't have now
Yes, now have
Yes had in past
no, never had
Do you have or had Immunity problems in past?
*
Choose one
Don't have now
Yes, now have
Yes had in past
no, never had
Do you have or had Women problems in past?
*
Choose one
Don't have now
Yes, now have
Yes had in past
no, never had
Do you have or had Joint Pain problems in past?
Choose one
Don't have now
Yes, now have
Yes had in past
no, never had
Do you have or had memory problems in past?
*
Choose one
Don't have now
Yes, now have
Yes had in past
no, never had
What type of problems do your currently have or need to improve?
Check those that apply
None
All
Energy
Choline
Minerals
Pain Relief
Weight Management
Attention Deficit
Water Purification
Hair Loss
Immune System
Relieve Stress
Menopause
Joint Health
Mental Outlook/ Memory
Liver
Allergies
Anger Management
Bone Density
Strengthen Heart
Cholesterol Regulation
Glucose Regulation
Sleep/ Relaxation
Detoxifying
Circulation
Oxygen in blood
Digestion/ Stomach
Blood Pressure
Prostate
Sports Nutrition
Air Purification
Skin Health
Environmental Health Household Cleaners
Other
If you would like a FREE consultation with Dr. Mels Carbonell? Enter Telephone number:
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How honest and accurate have you been with your answers?
Not at all
Somewhat
Fairly accurate
Very accurate
How did you hear about Wellness Dynamics?
Web Search
Church
Business
Friend
Uniquely You
Other
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