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Name
*
First
Last
Age
*
Height
*
Sex
*
Date
*
Email
*
Please enter your email, so we can follow up with you.
Please list your 5 major health concerns in order of importance:
*
Please list your 5 major health and fitness goals in order of importance:
*
Do you wish to gain, lose, or maintain your current body weight?
*
Feeling that bowels do not empty completely
Selected Value:
0
Category 1: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Lower abdominal pain relief by passing stool or gas
Selected Value:
0
Alternating constipation and diarrhea
Selected Value:
0
Diarrhea
Selected Value:
0
Constipation
Selected Value:
0
Hard dry or small stool
Selected Value:
0
Coated tongue or "fuzzy" debris on tongue
Selected Value:
0
Pass large amount of foul-smelling gas
Selected Value:
0
More than 3 bowel movements daily
Selected Value:
0
Do you use laxatives frequently
Selected Value:
0
Excessive belching, burping, or bloating
Selected Value:
0
Category 2: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Gas immediately following a meal
Selected Value:
0
Offensive breath
Selected Value:
0
Difficult bowel movements
Selected Value:
0
Sense of fullness during and after meals
Selected Value:
0
Difficulty digesting fruits and vegetables
Selected Value:
0
Undigested foods found in stools
Selected Value:
0
Stomach pain, burning or aching 1-4 hours after eating
Selected Value:
0
Category 3: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Do you frequently use antacids
Selected Value:
0
Feeling hungry an hour or two after eating
Selected Value:
0
Heartburn when lying down or bending forward
Selected Value:
0
Temporary relief from antacids, food, milk, carbonated beverages
Selected Value:
0
Digestive problems subside with rest and relaxation
Selected Value:
0
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine
Selected Value:
0
Roughage and fiber cause constipation
Selected Value:
0
Category 4: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Indigestion and fullness lasts 2-4 hours after eating
Selected Value:
0
Pain, tenderness, soreness on left side under rib cage
Selected Value:
0
Excessive passage of gas
Selected Value:
0
0 1 2 3 4 Nausea and/or vomiting
Selected Value:
0
Excessive passage of gas
Selected Value:
0
Stool undigested, foul smelling, mucous-like, greasy, or poorly formed
Selected Value:
0
Frequent urination
Selected Value:
0
Increased thirst and appetite
Selected Value:
0
Difficulty losing weight
Selected Value:
0
Greasy or high-fat foods cause distress
Selected Value:
0
Category 5: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Lower bowel gas and or bloating several hours after eating
Selected Value:
0
Bitter metallic taste in mouth especially in the morning
Selected Value:
0
Unexplained itchy skin
Selected Value:
0
Yellowish cast to eyes
Selected Value:
0
Stool color alternates from clay-colored to normal brown
Selected Value:
0
Reddened skin, especially palms
Selected Value:
0
Dry or flaky skin and/or hair
Selected Value:
0
History of gallbladder attacks or stones
Selected Value:
0
Have you had your gallbladder removed
Selected Value:
0
Crave sweets during the day
Selected Value:
0
Category 6: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Irritable if meals are missed
Selected Value:
0
Depend on coffee to keep yourself going or started
Selected Value:
0
Get lightheaded if meals are missed
Selected Value:
0
Eating relieves fatigue
Selected Value:
0
Feel shaky, jittery, tremors
Selected Value:
0
Agitated, easily upset, nervous
Selected Value:
0
Poor memory, forgetful
Selected Value:
0
Blurred vision
Selected Value:
0
Fatigue after meals
Selected Value:
0
Category 7: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Crave sweets during the day
Selected Value:
0
Eating sweets does not relieve cravings for sugar
Selected Value:
0
Must have sweets after meals
Selected Value:
0
Waist girth is equal or larger than hip girth
Selected Value:
0
Frequent urination
Selected Value:
0
Increased thirst and appetite
Selected Value:
0
Difficulty losing weight
Selected Value:
0
Cannot stay asleep
Selected Value:
0
Category 8: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Crave salt
Selected Value:
0
Slow starter in the morning
Selected Value:
0
Afternoon fatigue
Selected Value:
0
Dizziness when standing up quickly
Selected Value:
0
Afternoon headaches
Selected Value:
0
Headaches with exertion or stress
Selected Value:
0
Weak nails
Selected Value:
0
Cannot fall asleep
Selected Value:
0
Category 9: Please indicate the appropriate number “0 - 5” on all questions below (0 as the least/never to 5 as the most/always)
Perspire easily
Selected Value:
0
Under high amounts of stress
Selected Value:
0
Weight gain when under stress
Selected Value:
0
Wake up tired even after 6 or more hours of sleep
Selected Value:
0
Excessive perspiration or perspiration with little or no activity
Selected Value:
0
Tired, sluggish
Selected Value:
0
Category 10
Feel cold - hands, fed, all over
Selected Value:
0
Require excessive amounts of sleep to function properly
Selected Value:
0
Increase in weight gain even with low-calorie diet
Selected Value:
0
Gain weight easily
Selected Value:
0
Difficult, infrequent bowel movements
Selected Value:
0
Depression, lack of motivation
Selected Value:
0
Morning headaches that wear off as the day progresses
Selected Value:
0
Outer third of eyebrow thins
Selected Value:
0
Thinning of hair on scalp, face or genitals or excessive falling hair
Selected Value:
0
Dryness of skin and/or scalp
Selected Value:
0
Mental sluggishness
Selected Value:
0
Heart palpations
Selected Value:
0
Category 11
Inward trembling
Selected Value:
0
Increased pulse even at rest
Selected Value:
0
Nervousness and emotional
Selected Value:
0
Insomnia
Selected Value:
0
Night sweats
Selected Value:
0
Difficulty gaining weight
Selected Value:
0
Diminished sex drive
Selected Value:
0
Category 12
Menstrual disorders of lack of menstruation
Selected Value:
0
Increased ability to eat sugars without symptoms
Selected Value:
0
Increased sex drive
Selected Value:
0
Category 13
Tolerance to sugars reduced
Selected Value:
0
"Splitting" type headaches
Selected Value:
0
Urination difficulty or dribbling
Selected Value:
0
Category 14
Urination frequent
Selected Value:
0
Pain inside of legs or heels
Selected Value:
0
Feeling of incomplete bowel evacuation
Selected Value:
0
Leg nervousness at night
Selected Value:
0
Decrease in libido
Selected Value:
0
Category 15 (Males only)
Decrease in spontaneous morning erections
Selected Value:
0
Category 15 (Males only)
Decrease in fullness of erections
Selected Value:
0
Category 15 (Males only)
Difficulty maintaining morning erections
Selected Value:
0
Category 15 (Males only)
Spells of mental fatigue
Selected Value:
0
Category 15 (Males only)
Inability to concentrate
Selected Value:
0
Category 15 (Males only)
Episodes of depression
Selected Value:
0
Category 15 (Males only)
Muscle soreness
Selected Value:
0
Category 15 (Males only)
Decrease in physical stamina
Selected Value:
0
Category 15 (Males only)
Unexplained weight gain
Selected Value:
0
Category 15 (Males only)
Increase in fat distribution around chest and hips
Selected Value:
0
Category 15 (Males only)
Sweating attacks
Selected Value:
0
Category 15 (Males only)
More emotional than in the past
Selected Value:
0
Category 15 (Males only)
Are you a menopausal
Selected Value:
0
Category 16 (Menstruating Females only)
Alternating menstrual cycle lengths
Selected Value:
0
Category 16 (Menstruating Females only)
Extended menstrual cycle, greater than 32 days
Selected Value:
0
Category 16 (Menstruating Females only)
Shortened menses, less than every 24 days
Selected Value:
0
Category 16 (Menstruating Females only)
Pain and cramping during periods
Selected Value:
0
Category 16 (Menstruating Females only)
Scanty blood flow
Selected Value:
0
Category 16 (Menstruating Females only)
Heavy blood flow
Selected Value:
0
Category 16 (Menstruating Females only)
Breast pain and swelling during menses
Selected Value:
0
Category 16 (Menstruating Females only)
Pelvic pain during menses
Selected Value:
0
Category 16 (Menstruating Females only)
Irritable and depressed during menses
Selected Value:
0
Category 16 (Menstruating Females only)
Acne breakouts
Selected Value:
0
Category 16 (Menstruating Females only)
Facial hair growth
Selected Value:
0
Category 16 (Menstruating Females only)
Hair loss/thinning
Selected Value:
0
Category 16 (Menstruating Females only)
How many years have you been menopausal?
Selected Value:
0
Category 17 (Menstruating Females only)
Do you ever have uterine bleeding since menopause?
Selected Value:
0
Category 17 (Menstruating Females only)
Hot flashes
Selected Value:
0
Category 17 (Menstruating Females only)
Mental fogginess
Selected Value:
0
Category 17 (Menstruating Females only)
Disinterest in sex
Selected Value:
0
Category 17 (Menstruating Females only)
Mood swings
Selected Value:
0
Category 17 (Menstruating Females only)
Depression
Selected Value:
0
Category 17 (Menstruating Females only)
Painful intercourse
Selected Value:
0
Category 17 (Menstruating Females only)
Shrinking breast
Selected Value:
0
Category 17 (Menstruating Females only)
Facial hair growth
Selected Value:
0
Category 17 (Menstruating Females only)
Acne
Selected Value:
0
Category 17 (Menstruating Females only)
Increased vaginal, pain, dryness or itching
Selected Value:
0
Category 17 (Menstruating Females only)
How many alcohol beverages do you consume per week?
PART III
How many caffeinated beverages do you consume per day?
How many times do you eat out per week?
How many times a week do you eat raw nuts or seeds?
How many times a week do you eat fish?
How many times a week do you workout?
List the three worst foods you eat during the average week?
List the three healthiest foods you eat during the average week?
Do you smoke? If yes, how many times a day?
PART IV
Rate your stress levels on a scale of 1-10 during the average week.
Please list any medical condition(s) that you have been diagnosed with in the past:
Please list all medications you currently take and for what conditions:
Please list any natural supplements you currently take and for what conditions:
Has a doctor recommended that you take specific vitamins, minerals, or other supplements for your health? If yes, please list which ones:
Please list any allergies you have:
Are there any ingredients that may be found in a natural supplement that you are allergic to? If yes, please list which ones:
Are you aware of any supplements that may interfere with a medication that you are taking? If yes, please list which ones:
Do you have any concerns from taking natural supplements? If yes, please list your concerns:
Please list any other information that you believe is relevant that may affect your health or safety when taking a natural supplement:
If you require any clarification for the questions above, please contact our office prior to submitting your answers.
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