Dr. Wallach's Free Health Evaluation

PLEASE NOTE: It is very helpful for you to take this evaluation BEFORE using Dr. Wallach's supplements, then again AFTER using his supplements for at least 90 days.This is a great way to monitor your progress.

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

Within 24 hours (usually much sooner) you will receive an email with your total score in each of the 4 Health Categories and a link to schedule your FREE Telephone Consultation. During this brief call we discuss your scores with you so you can select the products that best meet your goals and your budget.

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

Who invited you to complete this Health Evaluation? *

Email address *

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

First Name *

Last Name *

Your State or Province * *

Your Country of Residence *

Your Zip Code/Postal Code *

Age *

Weight *

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

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) *