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Basic Info

Basic Info
Take 3-5 minutes to share a little about your health background and goals.

This will help identify nutritional deficiencies and shape your custom vitamin routine!
Sex (biological)*
- Female
- Male
Bump specializes in custom vitamin solutions designed to meet the unique nutritional needs of Women.

Please join our newsletter and we will email you regarding any future offerings designed for men.
Birthdate*
Weight
Height*

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Health History
Do YOU or anyone in your Immediate Family have a history of any of the following?
- Age Related Macular Degeneration
- Alzheimer's or Dementia
- Anemia
- Arthritis or Osteoporosis
- Breast Cancer
- Heart Disease
- High Blood Pressure
- High Blood Sugar or Diabetes
- High Cholesterol
- High Triglycerides
- Recurrent UTIs
- None of the Above
Do you have any allergies or avoid any of the following?*
- None
- Fish
- Gluten
- Sesame
- Shellfish
- Soy
- Tree Nuts
- Caffeine (stimulants)
Some of our products contain potential allergens. Please read product nutrition and ingredient information carefully.
Are you taking any medications?*
- Yes
- No
Before starting any new supplement routine, you should consult your doctor, pharmacist, and other healthcare providers about any dietary supplements and medicines you take.
Are you having a medical procedure in the next 2 weeks?*
- Yes
- No
We recommend speaking with your doctor before starting any new supplement routine and discourage starting any new supplementation programs prior to surgery without your doctor's approval.

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Your new vitamin routine will be unique to you... we print your name and your routine on each daily pouch!
We will also email you a copy of your routine when it is completed.
Name*
First
Last
Email*

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Reproductive Health
Are you...*
- Pre-Menopause (capable of menstruation)
- Menopausal (in-between)
- Post-Menopause (no menstruation)
When it comes to having children...*
- No Desire to Have Children
- Not Right Now (not sexually active OR using some method of birth control)
- Open to the Idea (no active birth control)
- Actively Trying (IVF or other Fertility Treatment)
- Currently Pregnant
- Currently Breast Feeding
- Proud Parent (not wanting additional children)
Is it a...
- Boy
- Girl
- Multiple
- Not sure
What trimester are you in?*
- First
- Second
- Third
- Not Sure
What is your projected delivery date?
Date Format: MM slash DD slash YYYY
Do you plan on breastfeeding?*
- Yes
- No
- Not Sure
Are you experiencing any of the following (related to your pregnancy)?
- Nausea
- Constipation
- Diarrhea
- None of the Above
Have you previously given birth?*
- Yes
- No
How many children do you have already?*
- 0
- 1
- 2
- 3
- 4
- 5+
Are you predisposed to any of these pregnancy related health issues?
- None
- Gestational Diabetes
- Hypertension
- Preeclempsia
- Difficulty Conceiving
- Low Birth Weight
- Preterm Labor
- Other
Please let us know what other pregnancy related health issue you are predisposed to....

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Diet and Digestion
How many servings of fresh Fruits and Vegetables do you consume on an average DAY?*
- 0
- 1 to 3
- 4 to 6
- 7+
How many servings of Red Meat do you consume in an average WEEK?*
- 0
- 1 to 3
- 4 to 6
- 7+
How many servings of Fish and or Seafood do you consume in a WEEK?*
- 0
- 1 to 3
- 4 to 6
- 7+
Do you get the recommended 25-35 grams of Fiber per DAY?*
- Yes
- No
- Not Sure
Do you have a senstive stomach or are you prone to nausea (not related to pregnancy)?*
- Yes
- No
Do you have any other digestive issues? (Bloating, constipation, gas, or irritable bowels?)*
- Yes
- No
Are you on a special diet?
- None
- Vegetarian
- Vegan
- Pescatarian
- Keto
- Paleo
- Kosher
- Halal
Some supplements may contain ingredients that conflict with certain diets. Please read all product nutritional labels carefully.

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Exercise and Lifestyle
How many times per WEEK do you Exercise for 15 mins or more?*
- 0
- 1 to 2
- 3 to 5
- 6+
What kind of Exercise do you do more of?
- Strength Training
- Cardio/Endurance/Flexibility
- Both
In a typical WEEK, how many times is your bare skin exposed to sunlight for more than 15 minutes (without sunblock)?*
- 0
- 1 to 3
- 4 to 6
- 7+
Are you a Smoker?*
- Yes
- No
How many alcoholic Drinks do you consume in a typical WEEK?*
- 0
- 1 to 3
- 4 to 6
- 7+

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Stress, Energy and Mental Health
How would you describe your emotional well being and mood?
- Poor
- Average
- Good
How would you describe the level of Stress in your life?
- Low
- Average
- High
Do you have trouble Sleeping?*
- Yes
- No
Do you have trouble Recovering from exercise? (e.g delayed or excessive soreness)*
- Yes
- No
Do you struggle with Low Energy?*
- Yes
- No

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Vision, Joint and Skeletal Support
Are you interested in Anti-Aging and/or Antioxidant support?*
- Yes
- No
Are you concerned about your hair/skin/nail health?*
- Yes
- No
Do you have issues with Appetite Control or Weight Loss?*
- Yes
- No
Have you had any UNINTENTIONAL weight loss?*
- Yes
- No
Are you trying to GAIN weight?*
- Yes
- No
Do you have issues with Joint or Bone health?*
- Yes
- No
Other than glasses or contacts, do you have issues with your Eyes?*
- Yes
- No
Weight Management, Aging and Appearance

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Environment and Pollutants
Do you feel like you get sick easily?*
- Yes
- No
Do you have seasonal Allergies?*
- Yes
- No
Personal Health Priorities
Estimate Shipping:*
ZIP / Postal Code
Finally, how did you hear about us?
- Internet Search
- Social Media Influencer
- From a Friend
- TV
- Article or Blog
- Facebook Page/Ad
- Instagram Page/Ad
- Podcast

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* These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent disease.
The FDA plays a specific role in regulating the nutraceutical industry. Learn More.

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support@bumpvitamins.com