Please answer each question honestly.

If your answer is Never → select NO
If your answer is Rarely, Sometimes, Occasionally, or Often → select YES

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Lack of energy (wake up tired/exhausted :45min-2hrs. after lunch) *

Yes

No

Sick more than 2x a year *

Yes

No

Body odor and/or bad breath *

Yes

No

Difficulty digesting food/Abdominal pain *

Yes

No

Eat meat more than 3x a week *

Yes

No

Monthly Female Concerns *

Yes

No

Recent or Frequent use of antibiotics (in last year) *

Yes

No

Regular alcohol consumption (2+ per week) *

Yes

No

Frequent mood swings (2+ week) *

Yes

No

Food allergies or gut pain after eating *

Yes

No

Bags under eyes *

Yes

No

Smoker *

Yes

No

Poor/lack memory of concentration *

Yes

No

Weak/poor Immune System *

Yes

No

Belching or gas after meals *

Yes

No

Stressful lifestyle (feel anxious) *

Yes

No

Skin or Complexion Issues *

Yes

No

Cravings — Sweets, salt or junk food/Late night eating *

Yes

No

Regular Dairy Consumption *

Yes

No

Frequent Depression or Listlessness *

Yes

No

Insomnia or Trouble Falling Asleep or Going Back To Sleep *

Yes

No

Menopausal Concerns *

Yes

No

Frequent Urination or UTI's *

Yes

No

Hair Loss *

Yes

No

Sore or Painful Joints *

Yes

No

Difficulty Maintaining Ideal Weight *

Yes

No

Low Endurance or Stamina *

Yes

No

Lack of a Balanced Diet *

Yes

No

Slow Recovery From Illness *

Yes

No

<2 Bowel Movements Per Day *

Yes

No

Lack of Appetite *

Yes

No

Low or No Sex Drive *

Yes

No

Brittle or Easily Broken Fingernails *

Yes

No

Poor High-Fat Diet *

Yes

No

Feeling Unsettled and/or Apprehensive *

Yes

No

Low Fiber Diet (<25mg/day) *

Yes

No

Muscle Cramps or Spasms *

Yes

No

Exposure to Air Pollution Daily *

Yes

No

Caffeinated Beverage (10oz+) Daily *

Yes

No

Feeling Out of Control or Overwhelmed *

Yes

No

Food or Chemical Sensitivities *

Yes

No

Recurrent Yeast or Fungal Infections *

Yes

No

Weak Bones, Teeth or Cartilage *

Yes

No

Suffers From Anxiety or Worry *

Yes

No

Easily Irritated or Angered *

Yes

No

No Regular Exercise *

Yes

No

Respiratory, Sinus or Allergy Issues *

Yes

No

First Name *

Last Name *

Today's Date *

Date of birth

Email *

Phone *

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