Post 4-Week Trial

Name *

NOTE: Type your name exactly as you did in the Pre 4-Week Trial Form

First Name

Last Name

Start Date of Aquaheal water consumption *

When did you start consuming your Aquaheal water?

MM

DD

YYYY

End Date of Aquaheal water consumption *

When did you end your trial period?

MM

DD

YYYY

Did you skip any days?

Select the days you skipped if applicable. Leave empty if you did not skip any days.

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 9

Day 10

Day 11

Day 12

Day 13

Day 14

Day 15

Day 16

Day 17

Day 18

Day 19

Day 20

Day 21

Day 22

Day 23

Day 24

Day 25

Day 26

Day 27

Day 28

Did you change your daily lifestyle?

If you did, in which aspect(s)

Increase in Physical Activity

Decrease in Physical Activity

Healthier Diet

Poorer Diet

Increase Medication

Decrease Medication