Name *

First Name

Last Name

Would you like more energy? *

Yes

No

Do you suffer frequent ill health (1/2 times per year)? *

Yes

No

Do you have body odour and/or bad breath? *

Yes

No

Do you have difficulty digesting certain foods? *

Yes

No

Do you eat red meat at least twice a week? *

Yes

No

Do you have problems with your monthly cycle? *

Yes

No

Have you used antibiotics/medication in the last 3 years? *

Yes

No

Do you regularly consume alcohol? *

Yes

No

Do you have mood swings? *

Yes

No

Do you have any food allergies? *

Yes

No

Do you have dark circles under your eyes? *

Yes

No

Do you smoke (including passive)? *

Yes

No

Do you have poor concentration or memory? *

Yes

No

Do you have poor resistance to unhealthy conditions? *

Yes

No

Do you experience discomfort after eating? *

Yes

No

Do you have a stressful lifestyle? *

Yes

No

Do you have any skin problems? *

Yes

No

Do you crave sweets/processed foods? *

Yes

No

Do you consume dairy products? *

Yes

No

Do you ever feel low, apathetic? *

Yes

No

Do you have inadequate/restless sleep? *

Yes

No

Do you have menopausal concerns? *

Yes

No

Do you have urination problems? *

Yes

No

Do you have brittle fingernails? *

Yes

No

Do you have any hair loss? *

Yes

No

Do you have a high fat/cholesterol diet? *

Yes

No

Do you have difficulty maintaining your ideal weight? *

Yes

No

Do you lack stamina? *

Yes

No

Do you have poor eating habits? *

Yes

No

Do you recover slowly from poor health? *

Yes

No

Do you have irregular/infrequent bowel activity? *

Yes

No

Are you edgy/unable to relax/tense? *

Yes

No

Do you have a low fibre diet? *

less than 30g per day

Yes

No

Do you have muscle discomfort? *

Yes

No

Do you have dry/damaged/dull hair? *

Yes

No

Are you exposed to air pollution? *

Yes

No

Do you feel sleepy when sitting? *

Yes

No

Do you have a lack of appetite? *

Yes

No

Do you drink 2+ cups of tea, coffee, cola per day? *

Yes

No

Do you ever feel out of control? *

Yes

No

Do you have any food/chemical sensitivities? *

Yes

No

Do you have problems with yeast/fungus? *

Yes

No

Do you have any muscle/joint discomfort or weakness? *

Yes

No

Do you worry excessively? *

Yes

No

Are you easily irritated/angered? *

Yes

No

Do you do insufficient exercise? *

Yes

No

Do you have problems with congestion/mucus *

Yes

No