Health Questionnaire

Take 2 minutes to fill this out and we will get back to you with a Personalized Program recommendation.

First Name: *

Surname or Family Name: *

Email Address: *

Age: *

Gender: *

Please answer the following questions.

Alcohol consumption: *

low

medium

high

Stress level: *

low

medium

high

Smoker?: *

Lacking energy?: *

Feel bloated?: *

Constipation?: *

Loose bowel movements?: *

Sore muscles?: *

Cravings?: *

Gas or belching?: *

Heartburn?: *

Overweight?: *

Anxiety or restlessness?: *

Recurring infections?: *

Urination problems?: *

Upset easily?: *

Tired in the morning?: *

Cloudy thinking?: *

High blood pressure?: *

High blood sugar?: *

Feel run down?: *

Additional comments:

Get Well - Stay Well