Pre 4-Week Trial Form

Name *

First Name

Last Name

Lifestyle Questions *

Select the option that is most accurate to you.

My days are highly stressfull

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I lead a very physically active lifestyle

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I maintain a very healthy diet/ I have healthy eating habits

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Health problems (not necessarily determined through blood tests)

You can select more than one. Categories S, M, L (S) Health problem that can be partially or totally treated in the short-term period of regular and consistent consumption of Aquaheal water (2-4 weeks). (M) Health problem that can be partially or totally treated in the medium-term period of regular and consistent consumption of Aquaheal water (1-2 months). (L) Health problem that can be partially or totally treated in the long-term period of regular and consistent consumption of Aquaheal water (3-6 months).

Respiratory system related diseases (S)

Kidney related diseases (S)

Inactivity (S)

Liver related diseases (M)

Digestive system related diseases (M)

Ear diseases (M)

Headaches (M)

Dizziness (M)

Immunity diseases (M)

Skin and joint diseases (L)

Health Problems (determined through blood tests)

You can select more than one. (S) Health problem that can be partially or totally treated in the short-term period of regular and consistent consumption of Aquaheal water (2-4 weeks).

Diabetes (S)

High blood pressure (S)

High cholesterol levels (S)

High triglyceride levels (S)