Would you like to know what products
could help you prevent disease
or significantly improve your health?

Use this form to help you discover what Shaklee products will help you
with health issues you have, or want to prevent.

Shaklee offers an unconditional money back guarantee!
All Information Received is Strictly Confidential.
We do not sell or give your information to anyone. We do not send unwanted E-Mail.

*This information is not intended to replace medical care, to diagnose, cure or treat illnesses.

*Please remember to add the email and name of the person who referred you*

*Name (Required)  
*E-mail (Required)    
*Your Guide's Email (Required)    
*Your Guide's Name (Required)  
Phone
Age
Gender Male Female
Please check off all of the health issues you have, or are concerned about and want to prevent.
The Basics - Always start with Vita-Lea to ensure a good foundation
B-Complex
Tired all the Time Crave Sweets Headaches Stress & more Stress
Mood Swings Rapid Heart Beat Ridges in Nails Skin Problems
Hair Loss Morning Sickness Carpal Tunnel PMS
Light Sensitivity Canker Sores Hyperactivity (A.D.D) Fibromyalgia
Using Birth Control Drink Alcohol Short Fuse (Temper) Feel Shaky/ Weak
Energizing Soy Protein Drink
Wake up Tired Mood Swings Poor Muscle Tone Difficulty Concentrating
High Cholesterol Low Blood Sugar Hormonal Imbalances Menopause Problems
Poor Digestion Slow Healing Carpal Tunnel Low Immunity
Osteoporosis Low Bone Density Dry Lifeless Hair Want to Prevent Cancer
Vita-C
Frequently Sick Chronic Infections Bruise Easily Varicose Veins
Allergies Cigarette Smoker Under Stress Cancer Prevention
Macular Degeneration Weakened Tooth Enamel Eat Processed Meats On Birth Control
Toxic Exposure Nose Bleeds Bleeding Gums Heart Disease
Vitamin E Complex
Heart Disease Asthma Poor Circulation Varicose Veins
Diabetes Slow to Heal History of Stroke PMS
Scarring Poor Night Vision High Cholesterol Phlebitis
Cold Hands/Feet Hot Flashes Cystic Conditions Blood Clots
Angina Shortness of Breath Autoimmune Disorders Leg Cramps
Please check off all of the health issues you have, or are concerned about and want to prevent.
Building Blocks
Calcium Magnesium
Muscle Cramps Twitches Insomnia Stomachs Cramps
PMS Arthritis Anxiety Noise Sensitivity
Teeth Grinding Bed Wetting Growth Spurts Fibromyalgia
Osteoperosis Bone Fractures Headaches Backaches
CarotoMax
Poor Vision Macular Degeneration Prostate Problems Lung Disease
Bronchitis Pneumonia Heart Disease Inflammations
Limited Fruits/Veggies Want to Prevent Cancer Cervical Abnormalities Skin Issues
Iron plus C complex
Anemia Very Pale Skin Dark Circles Under Eyes Stress & more Stress
Extreme Fatigue Heavy Menstruation Vegetarian Diet Excessive Exercise
Zinc
Poor Sense of Smell White Spots on Nails Dandruff Acne
High Stress Level Slow Wound Healing Diabetes Perspire Often
Fertility Problems Prostate Problems Weak Immune System Learning Challenges
Lecithin
High Cholesterol Poor Memory Concentration Problems Learning Challenges
Want to Lose Weight Gallstones Kidney Stones Eat Fatty Foods
Alfalfa
Allergies Asthma Arthritis Joint Pain
Gout Sinus Digestive Troubles Kidney Problems
Bad Breath Body Odor Constipation Acidosis
Fluid Retention Candida Bladder Infections Liver Toxicity
Please check off all of the health issues you have, or are concerned about and want to prevent.
Women's Health
GLA Complex
PMS Slow Metabolism Dry Skin Eczema
Fertility Problems High Cholesterol Arthritis Fibromyalgia
Loss of Hair Acne Psoriasis Dandruff
Menopause Balance Complex
Hot Flashes Sleep Disturbances Headaches Anxiety
Mood Swings Short Tempered Frequent Urination Depression
Please check off all of the health issues you have, or are concerned about and want to prevent.
Immune System
Nutriferon
Repeated Colds Asthma Allergies Infections
Want to Prevent Cancer Constant Sniffles Hives Weak Immunity
Defend and Resist Complex (DR)
Feel Illness Coming Have Bacterial Infection Have Viral Infection Low Blood Pressure
Please check off all of the health issues you have, or are concerned about and want to prevent.
Cardio Health
Omega-3 Complex
High Cholesterol High Triglycerides High Blood Pressure Heart Disease
Poor Circulation Migraines Eczema Psoriasis
Ulcerative Colitis Lupus Multiple Sclerosis Depression
Fibromyalgia Excessive Ear Wax Blood Clots Arthritic Pain
Garlic Complex
High Cholesterol High Blood Pressure Bacterial Infections Viral Infections
Sinus Infections Ulcers Allergies Asthma
Colitis Blood Sugar Problems Weak Immunity Yeast Infections
Co Q Heart (Co Q 10 enzyme)
Poor Endurance Shortness of Breath Irregular Heartbeat On Cholesterol Meds
Fatigue Poor Circulation Chest Pain Slow Metabolism
High Blood Pressure Fluid Retention High Cholesterol Gum Disease
Cholesterol Regulation Complex
High Cholesterol Overweight Sedentary Lifestyle Cigarette Smoker
On Statin Drugs History of Heart Disease History of Diabetes High Fat Diet
Please check off all of the health issues you have, or are concerned about and want to prevent.
Mind and Spirit
Stress Relief Complex
Feel Stressed Out Always Rushing Short Tempered Muscle Tension
Angry Outbursts Difficulty Concentrating Digestive Problems Anxiety Problems
Cor Energy
Constant Fatigue Physical Exhaustion Low Endurance No Initiative
Poor appetite Poor Circulation Low Body Temp Low Blood Pressure
High Levels of Stress Blood Sugar Irregularities Depression Weakness
Mental Acuity Complex
Trouble Concentrating A.D.D. Poor Memory Lack of Focus
Senile Stroke Vertigo Cochlear Deafness
Moodlift Complex
Depression Melancholy Loss of Interests Lack of Initiative
Sleep Disorders Emotional Distress Highly Stressed Easily Agitated
Gentle Sleep Complex
Insomnia Trouble Sleeping TMJ Headaches
Anxiety Rapid Heartbeat Stomach Cramps Menstrual Cramps
Please check off all of the health issues you have, or are concerned about and want to prevent.
Advanced Health
Liver DTX Complex
Liver Damage Hepatitis Cirrhosis Acne
Bad Breath Body Odor Food Allergies Canker Sores
Headaches Nausea Eat Greasy Foods Peeling Skin
Yellowish Skin Swollen Tongue Trouble Sleeping Bags Under Eyes
Glucose Regulation Complex
High Blood Sugar Type 2 Diabetes Crave Sweets Low HDL Cholesterol
Overweight Mood Swings Sedentary Lifestyle Frequent Thirst
Joint Health Complex
Osteoarthritis Joint Pain Backaches Sports Injuries
Gout Frequent Excerciser Collagen Disorders Cartilage Degeneration
Pain Relief Complex
Joint Pain Muscle Pain/Discomfort Lack of Flexibility Overexertion
Saw Palmetto Complex (For Men)
Enlarged Prostate Male over 30 Trouble Urinating Urinary Incontinence
Kidney Infections Excessive Fluid Retention Chronic Coughs Impotence
Please check off all of the health issues you have, or are concerned about and want to prevent.
Digestive Health
Optiflora Pre/Probiotic Complex
Digestive Problems Constipation Diarrhea Frequent Antibiotic Use
On Birth Control Sinus Infections Bloating after Meals Chronic Gas
Ear Infections Throat Infections Blurred Vision Fungal Infections
Anxiety attacks Pain/Tightening in Chest Memory Problems Muscle Aches
Sensitive to Perfume Rashes/Blisters in Mouth Vaginal/Bladder Infections Eczema
Stomach Soothing Complex
Acid Indigestion Bloating Discomfort After Eating Motion Sickness
Nausea Digestive Headaches Belching Morning Sickness
Abdominal Cramping Bad Breath Irritable Bowel Poor Digestion
EZ-Gest
Gas Belching Bloating Food Intolerances
Herb Lax
Constipation Hemorrhoids Small Bowel Movements Indigestion
Fill in any other symptoms or illness
you'd like help with
Please check off all of the health issues you have, or are concerned about and want to prevent.
I'm also interested in these targeted programs  (check one or more)
A Cleansing and Detoxifying Program Yes
4 Phase Health Building Program Yes
  Do you currently take vitamins? Yes No
  If yes how much of a difference do you feel?
  If yes how much do you spend a month on Vitamins?
  How do you choose the vitamins you buy? (check one or more)
  Quality   Brand Name   Ingredients   I buy what is convenient
  Price   Results   Clinical Research   I buy what people recommend
Are you interested in cleaners that are safe, toxin free and healthier for your family? Yes
Would you be interested in clean purified water without the hassle of bottled water? Yes
Are you interested in safe & natural products for babies and kids? Yes
Would you be interested in products that can help you burn fat without losing muscle? Yes
  I'd also like to know more about  (check one or more)
Reducing the signs of aging Reducing damage to my hair Using Natural Deodorants
Natural ingredient bath and body care Safe organic toothpaste    
Would you like to know how to get products for free? Yes
Would you like to know how we earn a great income teaching the Freedom Project? Yes
Comments or Questions