Vitamed LA Supplement Questionnaire

Choosing the right supplements can feel overwhelming. You probably ask yourself, 'Which brand is best and cleanest?' or 'Which brand is actually effective?' or simply 'What the heck should I even be taking?'. It is an exhausting process to say the least, and most people (myself included once upon a time) will feel defeated at the very start of their search and give up.

This is where I come in. Take a minute to complete this form. Within 2-3 days I will email you (from info@vitamedla.com) with any follow up questions, or in simpler cases I'll send you my recommendations directly.

Please note, the purpose of this questionnaire is not to give you medical advice, but rather help empower you to make the right choices in improving your general wellness and hopefully, quality of life.

Best wishes,

Daphna Shalom, PA-C (Founder and CEO of Vitamed LA, but also a real person, mom, career woman, and clean supplement seeker)

Name *

Email *

Phone *

Age *

Allergies

1. Please describe the patient's general health history. *

2. Is the patient pregnant? *

3. Is the patient on any medication? If so, which? *

4. Is the patient on any supplements? If so, which? *

Please include brands because many are loaded with heavy metals and other toxins.

5. What are the patient's goals? In order from most important to least. *

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

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