Health Appraisal Form

If you are interested in having this health questionnaire appraised by one our doctors, please fill out the following form. Upon completion, print the results by clicking on the "Print Page" link on the bottom of the page. Then mail the pages of the questionnaire, and include a check or credit card information (credit card number, expiration date, and billing address) for $90.00 to Country Health Store at P.O. Box 367 in Aberdeen, Idaho 83210. You may also call (208-397-4156) with your credit card information if you would like. Once we receive your questionnaire, one of the doctors will analyze it and we will mail you back a suggested nutritional supplemental program. If you are interested in knowing what nutritional supplements may be beneficial for your health related problems, please see our Signs and Symptoms page to see if your condition is listed.

Personal Information











Symptoms & Severity
Please rate on a scale of 0 (none) to 3 (severe)
For Men Only
Please rate on a scale of 0 (none) to 3 (severe)
For Women Only
Please rate on a scale of 0 (none) to 3 (severe)
Health History
Please select all those that apply to you and/or your health condition

Contact Us

P.O. Box 367
60 S. Main
Aberdeen, ID 83210
Office: 208.397.4156

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Disclaimer:  These products are not intended for use in the cure, mitigation, treatment or prevention of disease.  These are sold as nutritional supplements only.
Refund Policy:  Refunds must be requested within 30 days of the date of invoice.