People Wellness Program Introduction Questionnaire

In order for us to better understand your needs, please complete the confidential questionnaire below. We never share email addresses and do not reveal these results to third-parties.

Screen Shot 2015-10-24 at 6.46.56 PM Screen Shot 2015-10-09 at 8.53.12 PM Screen Shot 2015-10-10 at 4.04.27 PM Screen Shot 2015-10-11 at 12.18.48 PM

You can determine your personality profile here if you have not taken our survey already.

Your name (first, last):*
What is your marital status?
How many children do you have?:
What is your primary occupation?:
What is your primary source of income?:
What is your secondary source of income?:
Where are you in your career?:
What one thing would improve your career?:
How much extra income per month would satisfy your needs?:
How often do you exercise?:
Do you take dietary supplements?:
What one thing would improve your health?:
What are your hobbies and recreational activites?:
What one thing would make your life easier and improve your personal wellness?:
What is your personality profile?:
Are you open to new ideas regarding lifestyle and income sources?:
Is there anything else that you would like to add?:
Phone number for follow-up call:
-
Time of day for follow-up call:
Your email address (we never share):*
Thank you for submitting this questionnaire. 

Vitailia:
Registered address: 13835 North Tatum Boulevard, Suite 9-102, Phoenix, Arizona 85032
Business address: 4625 South Lakeshore Drive, Suite 309, Tempe, Arizona 85282
V: (602) 291-4595
F: (480) 718-8673 E: membership@vitailia.com