Energy and Vitality

Looking for energy and vitality advice?

The NHCO Nutrition® Laboratories invites you
to fill out this form in order to bring to you
personalized recommendations for your
current program.

*Sex : FM

*Age

*Diet

*I eat a varied and healthy diet
YesNo

*I take unbalanced meals on the go at least three times a week
YesNo

*My diet is low in fruits and vegetables
YesNo

*Physical activity

*Do you engage in fitness activities on a regular basis?
YesNo

*If yes, how often?
1-2 times a week≥ 3 times a week

*Your daily life

*Are you stressed?
YesNo

*Are you overworked?
YesNo

*Do you often feel lack of motivation?
YesNo

*Are you sleeping well at night?
YesNo

*Are you feeling tired when you wake up in the morning?
YesNo

*Are you feeling tired during the day?
YesNo

*Are you mentally tired?
YesNo

*Are you currently taking food supplements*?
YesNo

If yes, which one(s)?

*Are you currently undergoing a medical treatment*?
YesNo

If yes, please specify?

*Are you prone to allergies?
YesNo

If yes, please specify

*Are you intolerant to any foods?
YesNo

If yes, please specify

*Civility : MrsMsMr

*Last Name - First Name

Phone number

*Email

*I wish to be kept informed of the new products from NHCO Nutrition® Laboratories? YesNo

How did you hear about the NHCO Nutrition® Laboratories?
Pharmacy ConsultingPress, internet or social networksMedical prescription of a health professionalWord-of-mouth

Other

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