Digestion
Do you suffer from acid reflux / GERD? * Please select one.
Do you frequently feel nauseous (especially in the morning)? * Please select one.
Do you experience constipation or diarrhea? * Please select one.
Do you have frequent gas and/or bloating especially after meals? * Please select one.
Do you have bad breath / halitosis? * Please select one.
Do you have foul smelling and/or mucous covered stools? * Please select one.
Have you had yeast infections in the past? * Please select one.
Do you often crave sugary foods or sweets? * Please select one.
Do you have any food allergies? * Please select one.
Have you taken the birth control pill in the past? * Please select one.
Have you taken antibiotics more than two times in one year? * Please select one.
Have you been diagnosed with irritable bowel syndrome (IBS)? * Please select one.
Mental / Emotional
Do you tend to worry excessively? * Please select one.
Do you have any irrational phobias or fears? * Please select one.
Do you find falling asleep or staying asleep difficult? * Please select one.
Do you lack motivation or procrastinate often? * Please select one.
Do you have obsessive compulsive thoughts or behavior? * Please select one.
Do you suffer from mild depression or apathy? * Please select one.
Do you have low self esteem or lack confidence? * Please select one.
Do you often feel irritable or angry for No reason? * Please select one.
Do you find it difficult to focus or concentrate on the task at hand? * Please select one.
Hormones
Do you often wake up the morning feeling tired? * Please select one.
Do you struggle with losing body fat despite dieting and exercising? * Please select one.
Do you get cold easily (especially your hands and feet)? * Please select one.
Do you get shaky, dizzy, tired and/or irritable when you skip meals? * Please select one.
Do you suffer from PMS? * Please select one.
Do you suffer from peri / post-menopausal discomfort (e.g. hot flashes, weight gain, night sweats or insomnia)? * Please select one.
Do you suffer from anxiety and/or panic attacks? * Please select one.
Do you have a low sex drive? * Please select one.
Do you get dizzy when you stand up too quickly? * Please select one.
Do you often have severe fatigue in the afterNoon? * Please select one.
Do you feel it takes longer than it should to recover from exercise? * Please select one.
Do you have muscle and joint pain not related to a past injury? * Please select one.
Do you frequently have insomnia? * Please select one.
Do you find it difficult to deal with stressful situations? * Please select one.
Do you find that you cry easily or for no apparent reason? * Please select one.
Do you often crave salty foods? * Please select one.
Are you startled easily or sensitive to loud noises? * Please select one.
Do you have a ringing or hissing sound in your ears? * Please select one.
Detoxification
Are your eyes sensitive to bright lights? * Please select one.
Are you sensitive to strong odors? (i.e. perfumes, detergents, cigarette smoke, car exhaust). * Please select one.
Do you suffer from skin rashes or hives, for which the cause is unknown? * Please select one.
Do you have any amalgam fillings in your teeth? * Please select one.
Have you ever had a root canal? * Please select one.
Have you been frequently exposed to industrial or agricultural chemicals, such as solvents, cleaning fluids, paint fumes, plant sprays and fertilizers? * Please select one.
Do you smoke cigarettes? * Please select one.
Do you drink more than three alcoholic beverages per week? * Please select one.
Do you use recreational drugs? * Please select one.
Do you routinely use a cell phone or WiFi Internet access? * Please select one.
Nutrition & Lifestyle
Have you traveled outside of your home country? * Please select one.
Do you routinely go to sleep after 10:00 p.m.? * Please select one.
Do you participate in regular exercise? If yes, please list below.* Please select one.
Regular Exercise Frequency
Are any of your relationships causing you stress? * Please select one.
Do you often worry about your financial situation? * Please select one.
Would you consider yourself a workaholic? * Please select one.
Do you own any pets? * Please select one.
Do use a microwave oven on a daily basis? * Please select one.
Do you drink more than two caffeinated beverages per day? * Please select one.
Do you buy more Non-organic foods than organic foods? * Please select one.
Do you often skip meals? * Please select one.
Do you drink tap water? * Please select one.
Do you use artificial sweeteners? (i.e. Splenda, Sucralose, Aspartame, Acesulfame-K) * Please select one.
Do you consume sugary desserts often? (i.e. cakes, donuts, cookies, ice-cream) * Please select one.
Do you drink 6-8 glasses of water daily? * Please select one.
Do you lose more than two days of work per year due to illness? * Please select one.
Do you do shift work that requires you to stay up late? * Please select one.
Do you try and avoid fats when eating? * Please select one.
Medical
Have you had any major surgeries in the past? If Yes, please list below. * Please select one.
Major Surgeries Info
Have you had a serious illness? If Yes, please list below. *Please select one.
Major Illness Info
Are you currently under a physician’s care? * Please select one.
If you could eliminate one main health concern, what would it be?
Have you spoken to your physician regarding your health concerns? * Please select one.
Do you have a family history of any disease? If Yes, please list below. * Please select one.
Family Disease Info
Please list any prescription medications you are currently taking.
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Please list any over the counter medications and/or nutritional supplements you are currently taking.
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DISCLAIMER
By checking “I AGREE” you understand and acknowledge that the online health questionnaire is for educational purposes only and is not meant to diagnose, treat or cure disease. The free consultation is not meant to replace the medical advice of your primary care physician. The information you submit is strictly confidential and will never be shared with any other parties. * You must agree.
I AGREE
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