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	Fill out Health Questionnaire for Free Consultation
	Tell us a little about yourself and we will send you Free - a Nutritional Bar, Nutritional Sampler, Audio, and Information Pack - tailored especially for you. All fields marked with an asterisk* must be filled out.

First Name: * Last Name: * Address: *   City: * State: * AlabamaAlaskaAlbertaArizonaArkansasBritish ColumbiaCaliforniaColoradoConnecticutD.C.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineManitobaMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew BrunswickNew HampshireNew JerseyNew MexicoNew YorkNewfoundlandNorth CarolinaNorth DakotaNorthwest TerritoriesNova ScotiaNunavutOhioOklahomaOntarioOregonPennsylvaniaPrince Edward IslandQuebecRhode IslandSaskatchewanSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukon Postal Code: * Country: CanadaUSA E-Mail: * Day Phone: *

Do you shop in Health Stores? Yes       No

Do you buy organic produce? Yes       No

Do you take any supplements? Yes       No

What are they?

Do you take any prescribed or over the counter medications? Yes       No

What are they for?

Do you exercise? Yes       No

If yes, what?

Have you heard of any of these green foods? (Check all that apply) wheat grass       spirulina       chlorella       barley green       wild blue green algae

Have you heard about the new research on how wild blue green algae helps to fight cancer and virus cells? Yes       No

Are you interested in better...? (Check all that apply.) Energy       Endurance       Mental Clarity       Resistance to Illness       Digestion       Weight Control       Other (Explain)

What would be your health goals right now?

Would you like to work out of your home sharing natural and organic food supplements with free training we provide? Yes       No

Give us a good time to reach you? Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2009     12:00 AM12:301:001:302:002:303:003:304:004:305:005:306:006:307:007:308:008:309:009:3010:0010:3011:0011:3012:00 PM12:301:001:302:002:303:003:304:004:305:005:306:006:307:007:308:008:309:009:3010:0010:3011:0011:3012:00 AM(Other)

	Thank you for filling out our health questionnaire.

Wild and Organic Food
Ann & James Thompson
53 Eastlake Road
Mt. Pleasant, SC 29464
1-888-462-5423
1-800-455-9587 (voice mail)
Customer Service: james@wildandorganicfood.com