Q.1:
Do you experience low energy, complain of being fatigued, or feel regularly worn out?
Yes
No
Q.2:
Do you experience any food intolerances, sensitivities, or food allergies?
Yes
No
Q.3:
Does your skin get hives, rashes, itchy, eczema, Rosacea, Acne, Hives, Psoriasis, or other kinds of dermatitis?
Yes
No
Q.4:
Do you experience arthritis, joint pain, or muscle pain?
Yes
No
Q.5:
Do you have any digestive complaints like: constipation, diarrhea, indigestion, heartburn, gas, bloating, burping, acid reflux, GERD, IBS, or IBD?
Yes
No
Q.6:
Do you have any of the following autoimmune disorders - Type 1 Diabetes, Hashimoto’s, Rheumatoid arthritis, Lupus, Celiac, Multiple Sclerosis?
Yes
No
Q.7:
Do you crave sugar, bread, or alcoholic beverages?
Yes
No
Q.8:
Have you ever been bothered by prostatitis, jock itch, vaginal yeast infections, vaginitis, athlete’s foot, ringworm, or other chronic fungal infections of the skin and/or nails?
Yes
No
Q.9:
When exposed to perfumes, cigarettes, or strongly scented chemicals do you have a reaction of any kind?
Yes
No
Q.10:
Have you ever taken birth control hormones?
Yes
No
Q.11:
Do you have or have you ever had Post Traumatic Stress Disorder (PTSD)?
Yes
No
Q.12:
Do you have or have you ever had asthma?
Yes
No
Q.13:
Do you have or have you ever had allergies (pollen, pet dander, dust, mold, etc), sinus infections, polyps, chronic post nasal drip?
Yes
No
Q.14:
Do you experience spaciness, brain fog, chronic headaches, migraines, depression, anxiety, and/or ADHD?
Yes
No
Q.15:
Does your weight concern you?
Yes
No
Q.16:
Do you have allergies?
Yes
No
Q.17:
Experiencing digestive problems?
Yes
No
Q.18:
Is your energy level low more often than not?
Yes
No
Q.19:
Are you concerned about your hormone levels or are you experiencing hormonal imbalance?
Yes
No
Q.20:
Do you experience skin issues that concern you?
Yes
No
Q.21:
Have you been diagnosed with an autoimmune disorder?
Yes
No
Q.22:
Do you suffer from depression or anxiety?
Yes
No
Q.23:
How many bowel movements do you have per week?
Yes
No
Q.24:
How many bowel movements do you have per week?
1-2 Per Week
3-5 Per Week
1-3 every day
4+ per day
Q.25:
How many times have you taken antibiotics in your lifetime? If you aren’t sure, what is your best guess?
1-8
9-20
20+
Q.26:
How long were you breastfed for? If you aren’t sure, what is your best guess?
never
6 months or less
7-18 months
more than 18 months
Q.27:
Rate your stress levels on a scale of 1-10 - 1 being calm and peaceful all the time, 10 being completely stressed and highly charged.
1-3 (mostly peaceful, mild and calm)
4-6 (sometimes things bother me)
7-8 (things bother me more than most people)
9-10 (I'm almost always on edge)
Full Name
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Age