Supplement & Tea Intake Questionnaire Name* First Last Please check all supplements that you currently take regularly Select All Multivitamin/Multimineral Vitamin D (D2 or D3) Calcium B-Complex Fish Oil (EPA, DHA) Vitamin B12 Vitamin C Magnesium Flaxseed (ground or meal) Omega-3,6,9 Flaxseed oil Cod liver oil Echinacea Chondroitin Glucosamine Lycopene Vitalux (for eye health) Vitamin B6 Folic acid Iron Probiotic Protein "scoop" Of those supplements listed above, please describe your current dose, brand, frequency, and duration of intake of each.SupplementDoseBrandFrequency (i.e., once daily)Duration (length of intake) Do you drink tea? Yes No How often do you drink herbal tea?NeverMore than once per dayOnce per dayAt least once a weekLess than once per weekHow often do you drink Rooibos tea?NeverMore than once per dayOnce per dayAt least once a weekLess than once per weekHow often do you drink Black tea?NeverMore than once per dayOnce per dayAt least once a weekLess than once per weekHow often do you drink Green tea?NeverMore than once per dayOnce per dayAt least once a weekLess than once per weekHow often do you drink White tea?NeverMore than once per dayOnce per dayAt least once a weekLess than once per weekHow often do you drink Oolong tea?NeverMore than once per dayOnce per dayAt least once a weekLess than once per weekHow often do you drink Pu'er tea?NeverMore than once per dayOnce per dayAt least once a weekLess than once per weekDo you drink other types of tea? Please specify How often do you drink this "Other" type of tea?NeverMore than once per dayOnce per dayAt least once a weekLess than once per week
