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D&A Beverly Hills®




Survey

D&A Survey

Personal Information

Member ID (Please leave blank if you don't have one)  
First Name   
Last Name   
Gender    Male     Female
Age     Below 20     21-30     31-40     41-50     51-60   
 61 and above
Exercise     Daily
 Two Times a Week
 Once a Week
 Lives on the Couch
Alcohol     None
 Once a week
 Three times a week
 Always drunk
Smoking     None
 Once in a While
 When Drinking
 Chimney
Medication Taken     None
 
Pre-existing Medical Condition     None
 
Body Type    Petite     Slim     Average     Full Figured
Body Weight    Below 100 lbs.     101-130 lbs.     131-160 lbs.     161-190 lbs.   
 191-220 lbs.     221 lbs. and above
Blood Pressure    Low     Average     High   
Sugar Level    Low     Average     High   

D&A Beneficial Effects Indicators

Energy Boost, Increased Stamina or Endurance    None     Slightly     Moderately     Definitely   
Mental Clarity, Focus or Acuity    None     Slightly     Moderately     Definitely   
Feel Good Positives, Peace of Mind or Happy Mood Thought    None     Slightly     Moderately     Definitely   
Improved Skin Tone, Glowing Complexion or Firmness    None     Slightly     Moderately     Definitely   
Appetite Satiation, Reduced Hunger Pang or Forgetfulness of Eating    None     Slightly     Moderately     Definitely   
Rapid Fulness Sensation, Reduced Portion Size or Full After Few Bites    None     Slightly     Moderately     Definitely   
Detox Cleansing and Frequent Urination    None     Slightly     Moderately     Definitely   
Happy Number Two, Relaxed and Thorough Bowl Movement    None     Slightly     Moderately     Definitely   
Increased Lidido, Tactile Sensitivity or Want to Hug Desires    None     Slightly     Moderately     Definitely   
Restful Sleep and Morning Wide Awakening    None     Slightly     Moderately     Definitely   
Joint and Muscle Relaxation and Comfort    None     Slightly     Moderately     Definitely   
Improved Memory Recall and Heightened Senses    None     Slightly     Moderately     Definitely