1. Are you presently taking any type of nutritional supplements such as vitamins, minerals, herbs, amino acids, fish oils, etc?
   ______Yes ______No

2. Name the supplements that you are taking:
   
   

3. Who recommended you take these supplements?
   ______Family member or friend           ______Health Professional
   ______Advertisement                          ______Other
   
   

4. Where did you purchase these supplements?
   ______mail-order                               ______Healthcare provider 
   ______nutrition or vitamin shop           ______Other
   ______Pharmacy
            
   

5. If your doctor/dentist offered an advanced, high quality line of supplements, would you consider purchasing them?
   ______Yes ______No

6. If your doctor/dentist offered a simple genetic test to determine what supplemental regimen is best for you, based on your genetic variations, would you consider doing it? ______Yes ______No

7. If we offered a comprehensive weight management program, would you consider it? ______Yes ______No

     8.  If this practice offered a nutrition education program to improve your dietary habits, would you consider it
          by appointment with one of our staff?   ______Yes _______No, or  by a class exclusively for our patients? ______Yes _______No