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How it works
Natural Supplements
FAQ
Contact Us
Immune Genomic Support Questionnaire
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Immune Genomic Support Questionnaire
Immune Genomic Support Questionnaire
Immune Support Questionnaire
Step
1
of
3
33%
Please indicate how often you have had the following complaints
in the past 12 months:
Sudden high fever
(Required)
Never
Sometimes
Regularly
Often
(Almost) Always
Diarrhea
(Required)
Never
Sometimes
Regularly
Often
(Almost) Always
Headache
(Required)
Never
Sometimes
Regularly
Often
(Almost) Always
Skin problems (e.g. acne & eczema)
(Required)
Never
Sometimes
Regularly
Often
(Almost) Always
Muscle and joint pain
(Required)
Never
Sometimes
Regularly
Often
(Almost) Always
Common cold
(Required)
Never
Sometimes
Regularly
Often
(Almost) Always
Coughing
(Required)
Never
Sometimes
Regularly
Often
(Almost) Always
How do you feel
at this moment?
I score my general health the following grade
(Required)
(0 = very bad; 10 = very good)
Please enter a number from
0
to
10
.
I score my immune functioning the following grade
(Required)
(0 = very bad; 10 = very good)
Please enter a number from
0
to
10
.
C. Do you have reduced immune functioning at this moment?
Yes
No
D. Do you have a chronic disease? If yes, please specify:
Yes
No
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
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