HEALTH

Assessment Questionnaire

Evaluating your mental & physical health allows our team to personalize dosage instructions to maximize effectiveness of our products. Although not required, completing this form is highly recommended.

Added Rewards 💡

By completing the assessment questionnaire, you can enjoy a variety of extra benefits, such as:

📌 Proven Efficacy.
We evaluate whether microdosing is the right fit for you, ensuring that we never recommend something that will not deliver results.
📆 Healing Timeline.
By assessing your primary goals, we can determine how long it will take to see symptom relief and estimate the total duration needed for complete healing.
🔒 Safe Use.
With your individual health profile in mind, we design a personalized microdosing plan that keeps your safety a priority.
🔍 Cost Transparency.
After we design your personalized plan, we will review the cost together and help choose the lowest pricing option.
✨ Free Review.
The assessment results, valued at $80, are reviewed by our team at no cost when you place an order.

Contact 👤

Full Name:

First Name

Please enter at least 2 letters.

Last Name

Please enter at least 2 letters.

Phone:

Upload WhatsApp QR (Optional) In Settings , tap the QR icon to open your profile QR. Save to your device or attach a screenshot.

E-mail:

Enter a valid email (e.g. youremail@icloud.com).

Preferred Contact:

Please choose a contact method.

Basic Info 📋

Age:

Enter a valid age between 21 and 100.

Weight:

Please select pounds (lbs) or kilograms (kg).

Enter a valid weight.

Height:

Please select inches (in) or centimeters (cm).

Enter a valid height.

Gender:

Please choose a gender.

Status:

Please choose your relationship status.

Medication:

Please select an answer.

Health 🗂️

Diet:

Please select your diet quality.

Hydration:

Please select your hydration level.

Alcohol Use:

Please select your alcohol use pattern.

Smoking:

Non-smoker

Cigarettes

Marijuana

Vape Pens

Sleep:

Exercise:

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