Free Consultation Valued at $180 or More

All new vita® products are formulated to improve, strengthen and maintain a healthy body. They will also increase your vitality and zest for life. To receive your free consultation with Dr. Luke Cua, Ph.D., O.M.D., L.Ac., please complete this Questionnaire, all responses will be held in strict confidence. Dr. Luke Cua will email his personal recommendations to you.

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*First Name:

*Last Name:

*E-Mail Address:

Age:

Sex: Male Female

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Please check any conditions you have below and answer the related questions:

1. Tired in the morning After lunch After dinner
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

2. Need a nap after work/school/shopping - Under 1 hour Over 1 hour
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

3. Need extra hours of sleep Sleep poorly
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

4. Need to urinate during night - Once More than once
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

5. Weak urinary flow Delayed start Dribbling
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

6. Frequent bowel movements after meals
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

7. Weakness or heaviness in extremities Back
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

8. Poor appetite Poor sense of taste Frequent colds
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

9. Dry mouth Frequent bitter taste in mouth
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

10. Tired vision Weak vocal chords Don't like to talk
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

11. Poor hair condition Losing hair
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

12. Poor concentration Poor memory Nervous
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

13. Moody Upset easily Worry too much
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

14. Slow reaction time Premature signs of aging Poor coordination
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

15. Premature/weak ejaculation (men)
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

16. Difficulty reaching orgasm (women) Can't reach an orgasm
Poor Skin Condition
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

17. If youd like an herbal dietary supplement for your liver
How long have you experienced this condition?
What percentage of improvement have you achieved?

18. If under any kind of tumor treatment and wish to use an herbal dietary supplement for better health condition
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

19. If you have glucose and like an herbal dietary supplement for better health condition  
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

20.If you have  high cholesterol High triglycerides
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

21. If you have  rheumatoid arthritic and like an herbal dietary supplement for better health condition
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

22.If you have upset stomach and  like an herbal dietary supplement for your better health condition
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

23.If you have blemises (pimples)  and  like an herbal dietary supplement for your better health condition
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

24.If you have flu/cold or feel tire suddenly and like an herbal dietary supplement for better health condition
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

25.If you have chronic itch and like an herbal dietary supplement for your better health condition
How long have you experienced this condition?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?

26. Any other condition(s)?

How long have you experienced these conditions?
If you have been using a new vita® product for this condition,
What percentage of improvement have you achieved?