Name *

First Name

Last Name

Do you have pain between your shoulder blades or near your right shoulder on the back, that is separate from an existing injury?

Yes

Do you have a hard time digesting fatty foods?

Yes

Do you have greasy stools or stools that stick to the toilet bowl?

Yes

Do you get motion sickness (car, plane, train, bus etc)?

Yes

Do you have a history of morning sickness?

Yes

Do you get headaches over your eyes or sides of head?

Yes

Have you had your gallbladder removed?

Yes

Are you easily intoxicated when consuming alcohol?

Yes

Are you overly sensitive to chemicals, perfumes, tobacco smoke and cleaning agents?

Yes

Are you sensitive to synthetic sweeteners like aspartame?

Yes

Do you suffer from varicose veins or hemorrhoids?

Yes

Do you have food allergies, intolerances or sensitivities?

Yes

Do you have abdominal bloating after eating?

Yes

Are there specific foods that make you bloated?

Yes

Are you sensitive to wheat?

Yes

Do you have diarrhea regularly?

Yes

Do you feel spaced out sometimes?

Yes

Do you have chronic asthma or sinus infections?

Yes

Do you get sinus congestion?

Yes

Do you get alternating constipation with diarrhea?

Yes

Do you have a thick yellow or white coat on your tongue?

Yes

Have you taken antibiotics in the last year or over 4 times in your life?

Yes

Do you have extreme sugar cravings?

yes

Do you have mucus in your stools?

Yes

Do you have cramping in your abdomen?

Yes

Do you have less than 1 bowel movement per day?

Yes

Do you have hard and difficult to pass stools?

Yes

Do you have loose stools?

Yes

Do you have lots of foul smelling gas?

Yes

Do you have bad breath?

Yes

Do you have belching or gas after a meal?

Yes

Do you have heart burn or reflux?

Yes

Are you a vegan?

Yes

Do you have a history of iron deficiency?

Yes

Do you have undigested food in your stool?

Yes

Have you lost a taste for meat?

Yes

Do you have weak fingernails?

Yes

Do you feel full after normal sized meals?

Yes

Do you feel like skipping breakfast?

Yes

Do you have mid back pain?

Yes

Do you have a kidney stone history?

Yes

Does your urine have a strong odour?

Yes

Is your urine cloudy?

Yes

Do you have puffy eyes or dark circles under your eyes?

Yes

Do you have low blood pressure?

Yes

Are you a night person?

Yes

Do you have a hard time falling asleep?

Yes

Do you have a stressful job or lifestyle?

Yes

Do you suffer from dizziness when standing up suddenly?

Yes

Do you need sunglasses all the time when outside?

Yes

Do you like adding salt to a lot of foods?

Yes

Do you feel wired after drinking a coffee?

Yes

Do you have a hard time saying no?

Yes

Do you awaken a few hours after falling asleep and find it hard to fall back asleep?

yes

Do you crave sweets?

Yes

Frequent urination?

Yes

Do you crave sugar or coffee in the afternoon?

Yes

Do you get sleepy in the afternoon or after a meal?

Yes

Do you get shaky if meals are to spread out?

Yes

Do you get hangry?

Yes

Do you get a headache if you skip a meal?

Yes

Do you suffer from a skin condition? (acne, eczema, psoriasis, dermatitis, others)

Yes

Do you drink sugary drinks? (pop, juice, low sugar juices)

Yes

Do you drink plastic water bottles?

Yes

Do you heat food in plastic containers sometimes?

Yes

Do you use a cell phone/ computer for more than 3 hours per day?

Yes

Do you drink more than 2 alcoholic drinks per day?

Yes

Do you wear synthetic colongne or perfume?

Yes

Are you more than 15 lbs overweight?

Yes

Do you eat foods with preservative or dyes? (candy, packaged meals, orange cheddar cheese?

Yes

Do you frequently use aspirin, tylenol, or any over the counter medications?

Yes