Name

City

Lack of energy

Illness more than twice a year

Body odor and/or bad breath

Difficulty digesting certain foods

Eat meat more than 3 times a week

Monthly female concerns

Recent or frequent use of antibiotics

Regular consumption of alcohol

Frequent mood swings

Food allergies

Bags under eyes

Smoking

Poor concentration or memory

Poor resistance to disease

Belching or gas after meals

Stressful lifestyle

Skin/complexion problems

Cravings for sweets, salt or junk foods

Reqular consumption of dairy products

Feeling low, uninterested or depressed

Too little sleep or restless sleep

Menopausal concerns

Frequent urination or urinary concerns

Hair loss

Email

Postal Code

Sore or painful joints

Difficulty in maintaining ideal weight

Low endurance/stamina

Lack of a balance diet

Slow recovery from illness

Less than 2 bowel movements per day

Lack of appetite

Low sex drive

Brittle or easily broken fingernails

Dry, damaged or dull hair

High fat diet

Unsettled, apprehensive, pressured

Low-fiber diet

Muscle cramps or spasms

Exposure to air pollution daily

Caffeinated beverage (16 oz.) daily

Feeling out of control

Food/chemical sensitivities

Recurrent yeast/fungal infections

Weak bones, teeth or cartilage

Suffer from anxiety or worry

Easily irritated or angered

Don't exercise regularly

Respiratory, sinus or allergy problems