Vitamin D Optimization Consultation Form

Personal Information

First Name

Last Name

Email Address

Phone

GenderMaleFemale

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Have you had your Vitamin D levels tested in the last 12 months?YesNo

If the answer above is yes, what was your Vitamin D level? (if you know)

How many hours a day do you spend in direct sunlight?Less than two hoursTwo to four hoursFour or more hours

Do you wear sunscreen regularly?DailyA few times per weekRarely

Do you spend most of your time:IndoorsMixedOutdoors

Do you live in a low sunlight area?YesNo

Are you currently taking Vitamin D?YesNo

If the answer above is yes, please list the brand and dose you are taking.

Does your Vitamin D supplement contain: (check all that apply)K1K2

Do you supplement with Magnesium?YesNo

If the answer above is yes, please list the brand, type of Magnesium (e.g. Magnesium Lactate, Glycinate, Citrate, etc.), and dose you are taking.

List any other current health conditions.

List all prescription medications you are currently taking.

Allergy Types *NoneFoodDrugEnvironmental

Allergy Details

How ready are you to follow a plan?Very ReadySomewhat ReadyNot Ready Yet

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