Tincture Bar Step 1 of 9 11% For each of the 3 issues in this section, please indicate if it is MOST IMPORTANT, MORE IMPORTANT, or LEAST IMPORTANT. Please only list each response 1 time on the 3 issues.Pain ReliefMost ImportantMore ImportantLeast ImportantStress ReliefMost ImportantMore ImportantLeast ImportantSleep IssuesMost ImportantMore ImportantLeast Important HealthOverall health plays an important role in knowing how best to make suggestions for your customized tincture. How would you rate the following general lifestyle categories?Diet / Eating HabitsVery HealthySomewhat HealthyNeither Healthy no UnhealthySomewhat UnhealthyVery UnhealthySleeping PatternsVery HealthySomewhat HealthyNeither Healthy no UnhealthySomewhat UnhealthyVery UnhealthyExercise RoutineVery HealthySomewhat HealthyNeither Healthy no UnhealthySomewhat UnhealthyVery Unhealthy THCSome products contain trace amounts of THC (0.3% or less). While many find it helpful, others would rather not have it because it may come up positive in a drug screening for work, school, etc.THCYesIndifferentNoDo you want to have trace amounts of THC (0.3% or less) in your custom tincture? WeightWeightLess than 150 lbs.150lbs. - 250 lbs.More than 250lbs.In order for us to make the best suggestion possible, please choose which weight category you fit into. PainPlease Answer the following questions related to PAIN.Physical Pain 0 - Not at All 1 2 3 4 5 6 7 8 9 10 - All the Time On a scale from 1 to 10, how much does PHYSICAL pain affect your daily life?Time of DayOn average, how does PHYSICAL pain affect you during the following times of the day? (1 = no pain, and 5 = Chronic pain)In the Morning1 - No Pain2345 - Chronic PainThroughout the Day1 - No Pain2345 - Chronic PainIn the Evening1 - No Pain2345 - Chronic PainThroughout the Night1 - No Pain2345 - Chronic PainActivitiesOn average over the last few weeks, how has PHYSICAL pain affected you while performing these regular daily activities? (1 = no pain, and 5 = most painful)Getting Out of Bed1 - No Pain2345 - Most PainfulCasual Walking1 - No Pain2345 - Most PainfulClimbing Stairs1 - No Pain2345 - Most PainfulWriting / Typing1 - No Pain2345 - Most PainfulDriving1 - No Pain2345 - Most Painful StressPlease answer the following questions related to stressStress 0 - Not at All 1 2 3 4 5 6 7 8 9 10 - All the Time On a scale from 1 to 10, how would you rate your overall stress level?ActivitiesOn average how does STRESS affect the following regular daily activities? (1 = no affect, and 5 = greatly effected)Social Interaction1 - No Affect2345 - Greatly AffectedWork / School1 - No Affect2345 - Greatly AffectedLeisure Time1 - No Affect2345 - Greatly AffectedEating Habits1 - No Affect2345 - Greatly AffectedSleep Patterns1 - No Affect2345 - Greatly Affected SleepSleep 0 - No Problems 1 2 3 4 5 6 7 8 9 10 - Major Problems On a scale from 1 to 10, how would you rate your overall satisfaction with your natural sleeping habits?ActivitiesOn average how would you rate your ability to perform the following sleep related activities? (1 = no affect, and 5 = greatly effected)Falling Asleep1 - No Difficulty2345 - Great Difficulty Your InformationCompleting the form will create a user profile for you on the Native Ceuticals website and store your Tincture data in your profile.Name First Last Email PhoneUsername Password Enter Password Confirm Password Shipping Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PurchaseCompleting the final portion of this form signifies your agreement to purchase the custom tincture product that will be produced for you and your agreement for the price of the tincture to be charged to the credit card you enter below.Custom Tincture* Price: $129.99 Custom tincture prepared for you based on your answers to the questions asked on this form.Credit Card* Cardholder Name Card Details
