Dr. Wallach's Free Health Evaluation

PLEASE NOTE: It is very important that you take this evaluation BEFORE using Dr. Wallach's products, then again AFTER using the products for 30 days, 60 days, and 90 days.This is the best way to accurately monitor your progress.

Once you complete the evaluation a "Success Notification" should appear on your screen stating that the form was successfully submitted.

BE ASSURED that your information is confidential and will not be shared with anyone except your Personal Health Coach.

Email address *

Which Health Evaluation is This For You? *

Initial (Before starting using our products)

30 Day (After using our products for 30 days)

60 Day (After using our products for 60 days)

90 Day (After using our products for 90 days)

Date: Use this format (MM/DD/YYYY) or just click on the calendar icon to select today's date. * +

First Name *

Last Name *

Your Country of Residence *

Your Zip Code/Postal Code *

Age *

Weight *

What is your most important health goal in the next 90 days? *

What is your monthly budget? How much can you spend each month to meet your 90 Day Health Goal? (This information is simply a general guideline and helps us determine the best health plan for your personal needs) *

Have you ever used Dr. Wallach's products? *

Yes

Phone/Text Number (no spaces or dashes) *