Name
*
First Name
Last Name
Email
*
Date
*
MM
DD
YYYY
Street Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone or Cell
*
(###)
###
####
Who can we thank for referring you?
*
Digestive
Please check all that apply -
Over acid
Under acid
Stomach problems
Hiatal hernia
Other
Other
# of meals per day
Emotional/Nerves
Please check all that apply -
Mood Swings
Depression
Anxiety, Fear, or Nervousness
Anger, Irritability
Other
Other
Lymph, Skin
Please check all that apply -
Do you sweat often?
Do you use an antiperspirant?
Hives, Rashes, Dry Skin, Acne
Other
Other
How many times per week do you exercise?
How often do you have headaches?
Hair/Nails
Please check all that apply -
Hair Loss
Poor Nails
Other
Other
Mind
Stress, Poor Memory/Concentration
Other
Other
Elimination/Colon
Diarrhea
Constipation
Other
# of bowel movement(s) per day/week
Other
Glands
Irregular Periods
PMS/Menopause Symptoms
Other
Other
Urinary
Water Retention
Kidney/Back Pain
Other
Other
Energy/Activity
Fatigue/Sluggishness
Hyperactivity/Insomnia
Other
Other
Respiratory
Chest Congestion/Coughing/Pain
Asthma/Bronchitis/Allergies
Stuffy Nose/Sinus Problems
Other
Other
Head/Ears/Eyes/Mouth/Throat
Earaches/Ear Infection
Ringing in Ears/Hearing Loss
Blurred/Poor Vision
Sore Throat/Hoarse
Other
Other
Circulation/Heart/Joints
Irregular/Rapid Heartbeats
Chest Pain
Poor Circulation
Arthritis Pain or Aches in Joints
Other
Other
Weight
Under/Over Weight
Binge Eating/Drinking
Craving Certain Foods
Other
Other
Current medication(s)
Are you allergic to anything?
Other
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Date
MM
DD
YYYY