Nutriton Consultation Quiz

Gender *

Female

Male

Prefer not to say

Email *

Mobile Number (for WhatsApp follow-up) *

Location (City, State) *

Hair fall / thinning

Insomnia or poor-quality sleep

Frequent colds / low immunity

Menopause-related symptoms (hot flashes, mood swings)

Stress or fatigue

Brittle nails / dull skin

Other

Do you follow a specific diet?

No specific diet

Vegetarian

Vegan

Gluten-free

Dairy-free

Intermittent fasting

Keto / Low Carb

High Protein

Other

Are you currently following a diet chart or nutrition plan?

Yes

No

How would you rate your stress level?

Low

Moderate

High

Very high (burnout, fatigue)

Average sleep per night:

Less than 5 hours

5–7 hours

More than 7 hours

Water intake per day:

Less than 1 Litre

1–2 Litres

More than 2 Litres

Physical activity level:

Sedentary (no regular exercise)

Light activity (walks, yoga)

Active (3–4 workouts/week)

Intense (athlete, gym daily)

Are you currently taking any medications?

No

Yes

Are you taking any vitamins or herbal supplements?

No

Yes

Any allergies to vitamins, herbs, or food ingredients?

No

Yes

What matters most to you in a supplement?

Plant-based / herbal

Sugar-free

Doctor-formulated

Scientifically backed ingredients

Fast results

Safe for long-term use

Gluten/dairy-free

Have you used health gummies before?

Yes

No

How soon are you looking to start a supplement plan?

Immediately

Within 1–2 weeks

Just exploring

Would you like our in-house expert to personally review your form and connect with you?

Yes, I'd love a free nutritionist consultation

No, just send product recommendations

Preferred mode of contact:

Phone Call

Email

Personalized Nutrition Assessment Form

Hair Fall / Thinning Details

Sleep Issues Details

Low Immunity Details

Menopause Symptoms Details

Thank You!