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Name:
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Email
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Which medications, if any, do you currently take that has restrictions
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Symptoms of a Thin Myelin ShealthingDoes noise, people or commotion get on your nerves?
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Do you have to recheck things?
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Do you have a hard time remembering your dreams every day (for about 20 min after awakening)?
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Do you try to avoid large groups of people or noisy places?
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Do you hear voices or sounds which are not there?
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Do you have a hard time concentrating when things are going on around you?
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Do you have invasive thoughts?
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Do you play the radio, TV, fan or air conditioner (white noise) to help you sleep better or help you fall to sleep?
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Does sudden noises startle you?
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Do you have rituals that you need to do to feel you did something right?
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Do you tend to turn things off or down when someone is talking to you?
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Have you had the sensation that someone has touched you or is sitting or standing next to you but no one is there?
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Do you ever think you see someone or something out of the corner of your eye but when you turn your head, nothing is there?
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Do you forget where you are or what direction a place is that you have gone to often?
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Do you forget common words or names?
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Do you have a hard time getting a song out of your head?
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Do you feel compelled to say your prayers over and over again, fearing you have not said them right?
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Symptoms of a Weak or Toxic LiverHow often do you have bowel movements?
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Do you get night sweats?
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Do the muscles in the shoulder/neck area get tight?
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Do you feel bloated after you eat?
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Do you have flatulence (passing gas) more than 1 time a week?
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Symptoms that the liver is not balancing blood sugar levels include: getting either shaky, weak, grouchy or aggressive. If you skip a meal do you experience any of the above? Or have you been diagnosed as having hypoglycemia?
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Do you have diabetes or feel like taking a nap after you have eaten a large meal?
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Symptoms that the liver is not balancing blood sugar levels include: getting either shaky, weak, grouchy or aggressive. If you skip a meal do you experience any of the above? Or have you been diagnosed as having hypoglycemia?
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Do you have diabetes or feel like taking a nap after you have eaten a large meal?
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Do you wake up at night (to urinate or fluff the pillows or look at the clock, etc.) between 1 and 5 and then go back to sleep?
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Do you have or have you ever had psoriasis, eczema, boils or acne?
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Do you have or have you ever had moles or skin tags?
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What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol?(Please give exact number, if not sure please put "not sure")
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What is your total cholesterol number?(Please give exact number, if not sure please put "not sure")
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What is your triglyceride number?(Please give exact number, if not sure please put "not sure")
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Are you on cholesterol medicine?(Please list all)
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Have you ever had hepatitis or cirrhosis of the liver?(Please list all)
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If female, do you have or have you ever had cysts on your ovaries? If male, mark never
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If female, do you have or have you ever had heavy or clotty, frequent or missed menses (periods or menstruation), or endometriosis? If male, mark never
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If female, have you had fibroids, tumor in breast or uterus? If male, mark never
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If female, do you have or have you ever had mood swings, PMS, or menopausal problems? If male, mark never
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Have you ever had hot flashes?
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If male, have you ever had a high PSA or swollen prostate (including prostate cancer)? If female, mark never
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Symptoms of a pH imbalance -- acidosis or alkalosisDo you happen to know your saliva and urine pH? If so please put here
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Do you suffer from sinusitis or have mucus in the head area or nasal drip?
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Do food or pills feel like they get stuck in your esophagus?
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Do you have any stiffness or cracking in your joints?
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Do you experience muscle weakness or soreness?
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Do you have more than 5 bowel movements a day or diarrhea?
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Have you experienced a weakness or discomfort in the lower back?
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Do you get acid reflux or heart burn?
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Do you have high blood pressure?
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Do you retain water or have puffiness under your eyes?
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Do you get charley horses?
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Do you know if you have any plaque build up in your arteries?
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Symptoms of a Glandular WeaknessWhat is your body temperature ? (Give Exact number in Fahrenheit, do not put normal)
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How many moons do you have on the bottom of your fingernail cuticles?
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Do you feel as tired when you wake up as you did when you went to sleep?
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Do you gain weight easily?
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Do you experience sensitivity to the cold?
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Do you experience mood swings and/or depression?
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Have you noticed reduced initiative?
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Do you have a lower level of stamina?
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Do you now or have you ever had LOW blood pressure?
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Does your skin get dark where clothes or skin rubs (for instance around the pant waist band or bra or inner thigh)?
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Do you have a hard time getting to bed early AND do you have a hard time awakening early in the morning?
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Do you have an energy dip around 2 to 3 pm and then get your second wind later on?
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Symptoms of Yeast OvergrowthHave you taken antibiotics or birth control?
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Do you have dry or cracked or rough skin on your feet, heels or hands?
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Do you have chronic fatigue?
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Do you feel the urge to urinate frequently OR when your bladder is not full?
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Do you get jock itch (male) or vaginal yeast infections (female)?
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Do you get thick toenails or have fungus on your toenails?
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Symptoms of a Weak DigestionDo you burp more than 2 times a week? (not including after drinking soda)
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Do you have rough skin around your nails or hangnails on hands or feet?
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Do you have a crease down the middle of your tongue?
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Do you feel hungry soon after you eat?
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Do you feel sick after you eat or if you skip a meal?
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Symptoms of a Vitamin or Mineral DeficiencyDo you crave milk products?
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Do you crave sweets?
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Do you crave salty foods?
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Do you crave potato chips?
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Do you crave fatty foods?
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Do you crave alcohol?
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Do you crave chocolate or coffee?
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Do you crave ALL foods?
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Does your heart ever flutter?
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Do you have lower back pain?
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Do you get Charley horses (muscle cramps)?
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Do you retain water?
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Do you have high blood pressure?
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Do you have hemangiomas (looks like a little blood mole), varicose veins, or spider veins?
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Do your gums bleed when you brush your teeth?
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Do you get cracks or sores in the corner of your mouth?
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Do you have ridges in your fingernails?
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Do your eyes get dry?
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Blood Sugar Balance SymptomsAre you a diabetic?
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If you eat a large meal do you feel tired or sluggish?
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Have you ever been diagnosed with hypoglycemia (low blood sugar)
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If you skip a meal do you feel ANY of the following? weak, headachy, grouchy, aggressive, or depressed?
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Symptoms of Circulatory ProblemHave you needed bypass surgery or angio plasty?
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Do your hands or feet get cold, fall asleep, get numb, or experience the sensation of needles?
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Do you get out of breath easily?
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Do you get chest pains or pains radiating down the left arm or up to the left jaw?
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Have you been diagnosed with any heart conditions?
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Symptom of Gallbladder ProblemHave you ever been diagnosed as having a gallbladder problem?
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Have you ever had your gallbladder removed?
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Does greasy food upset your stomach?
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Do you ever get a pain under your right rib cage or up between the shoulder blades?
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Do you fell sick or vomit green/yellowish bitter fluid?
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Do you usually skip breakfast because your stomach feels queezy or not ready for food inthe mornings?
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Symptoms of Respiratory ProblemHave you ever been diagnosed with a lung disease?
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If you have been diagnosed with a lung disease, what is the name of the disease?
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Do you consume milk products on a daily basis?
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Do you smoke?
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Do you get 1 productive (loose mucus cleanse) cold a year?
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Do you get out of breath easily?
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Can you inhale for 10 counts, hold for 10 counts and exhale for 12 counts?
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Emotions Can Effect HealthDo you get angry EASILY?
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Are you Extremely nurturing?
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Are you OVERLY impulsive?
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Do you change your personality to mirror the people you are with?
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Are you fearful?
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Do you LACK joy in your life?
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Do you LACK a close relationship to God (i.e. do you feed the spiritural part of your self sufficiently)?
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Have you every been diagnosed with a disease or health condition? If so please list all.
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Are you on any medication which has diet or supplement restrictions? If so please list.
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Are you on a blood thinner or have a bleeding disorder?
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Are you on SSRI's?
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What is your birth date? MM/YR*
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What is your email?
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If you have a discount coupon, please enter coupon # here*
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How did you hear about us?
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