Full Name :

Age

Full Address :

Contact Telephone :

Email Address :

Gender : Gender : Male Female Other

Would you recommend Immune Tea to other people? Would you recommend Immune Tea to other people? Yes No

How long have you been taking Immune Tea? How long have you been taking Immune Tea?1-3 Months3-6 Months6-9 Months9-12 Months1 Year +

Would you say while taking Immune Tea has a positive change in your mood, health and fitness? Would you say while taking Immune Tea has a positive change in your mood, health and fitness? Extremely Very Moderately Slightly Not at al

Do you suffer from an illness? Do you suffer from an illness? Yes No

If Yes, what illness do you suffer from? (If No, type none.)

Has Immune Tea helped you with your illness? Has Immune Tea helped you with your illness? Yes No

If yes, How would you describe this improvement?

Do you take Immune Tea alongside any medication? Do you take Immune Tea alongside any medication? Yes No

If yes, what medication do you take?

Have you noticed improvements in your energy levels, on a scale of 0 to 10? (if no change please select 1) Have you noticed improvements in your energy levels, on a scale of 0 to 10? (if no change please select 1) 1 2 3 4 5 6 7 8 9 10

Do you suffer from headaches? Do you suffer from headaches? Yes No

If you have headaches would you take Immune Tea instead of taking tablets? If you have headaches would you take Immune Tea instead of taking tablets? Yes No

Have you noticed any improvements in your headaches while taking Immune Tea? Please describe these improvements.

Do you suffer from lack of sleep? Do you suffer from lack of sleep? Yes No

If yes, has Immune Tea helped you get a good nights sleep? If yes, has Immune Tea helped you get a good nights sleep? Yes No

Do you suffer from inflammation? Do you suffer from inflammation? Yes No

If yes, have you noticed any reduction in inflammation when taking Immune Tea? Please describe below.

Has your body shown signs of having a stronger immune after taking Immune Tea? Has your body shown signs of having a stronger immune after taking Immune Tea? Yes No