Nutrition & Health Analysis
DIRECTIONS: Print out this questionnaire. Answer all the questions as best you can. Mail the completed pages with a payment of $25 ($15 if a member) check or money order (in US Dollars) to the address on page 4. If you are unable to print this form, we will mail this questionnaire to you, click here to request a mailed form. Once we have received your questionnaire we analyze your nutritional/health needs and send the following:
You'll Receive:
1) Detailed easy to follow customized food program to get you on the road to feeling better
2) Supplement and Herbal recommendations for your particular health needs
3) Complete exercise program that you can maintain and enjoy
4) Important information on contacts and support for you
All information given to us is kept strictly confidential.
You're on the road to your recovery!
(This questionnaire is not meant to diagnose illnesses, or to replace medical care. Please talk to your doctor about any concerns you have about your health, after receiving your reports, please show them to your doctor and talk about the results.)

Country:___________________

Phone: ___________________ Gender:_____

E-mail : ________________________

Height: ______ Weight:_______ Age:______

Occupation:___________________________

Are you working at present:_________
If no, and it is due to health related problems please explain:

Are you taking medication prescribed and/or over the counter?________
If yes, list the kind and dosage, how often taken, and for what reasons.



Are you taking nutritional supplements/herbs?_________
If yes, list the kind and dosage and whether it is taken on a regular basis, please include herbal drinks.




Do you exercise?
If yes, list type of exercise, duration and how often per week. If no, explain why.

Do you smoke, use nicotine patches, or chew tobacco?
If yes, list how much you use, and for how many years.

Approximately how many glasses of water do you drink per day?__________
Is the water usually regular tap water, or special water such as distilled or well water?

Do you consume caffeine?_______
If yes, how much per day? For example, 3 cups coffee, or 5 sodas.

When you have a snack, what type of food do you prefer?
For example, sweet roll, cookies, cheese, crackers, fruit, vegetables.

Do you have to watch what you eat:
to avoid gaining weight?______or avoid losing weight?______ Do you want to lose weight? ______

Do any foods seem to irritate you in some way? ______
If yes, name the foods and describe the problem.

Do you have any allergies? ______ If yes, please list all.

Nutrition Analysis: Write down your typical intake for three days. It is important to put down everything you eat and drink, including snacks, candy, coffee, wine, beer, and the amount, by weight or measurement.
Please list fast food and prepackaged meals by brand name.

Do you eat fast, fatty, fried or processed food?______ If yes, how often ?
Do you often have cravings for sweets and/or processed foods? _______
Do you ever feel bad enough to go to the doctor, but are told, "everything is fine"?_______
Have you ever been exposed to antibiotics, steroids, chemicals, sedatives, stimulants or pesticides?_____ If yes, please list and give dates.


Do you have dull or brittle hair and nails?________
Have you had athlete’s foot, ring worm, "jock itch" or other chronic fungous infections of the skin or nails? _______ If yes, please list.
Do you have white spots on your nails?__________ or cracks and sores at corner
of mouth?_____ or suffer from canker sores?_________
Do you have a bowel movement everyday day? _______ If no, how often?
Do you use laxatives?______ If yes, how often?
Do you often feel fatigued or out of energy?_________If yes, how often?
Do you get headaches?________ If yes, how often and what kind? (sinus, migraine, etc.)

Are you frequently ill?________ If yes, please list illnesses if known and symptoms.


How do you sleep? (explain how much sleep you get on average, do you feel rested, do you wake up too early or too often? Do you get insomnia? how often etc.)


How much stress do you experience? On a scale of 1 to 10 with 1 being the least.

What do you do to de-stress?
Do you have menstrual/menopause problems? _____ If yes, please describe:

Do suffer from frequent yeast infections?_______
Do suffer from frequent urinary tract/bladder infections?________
Do you have children?_______
c- section(s)______or natural birth(s)______
Do you ever feel low, uninterested, depressed, or experience anxiety?_______
if yes, please explain.

Do experience sore or painful joints? _________ Sore or painful muscles?_______
Do you have unexplained nerve pain?______
If yes, where and how often:

Vision Problems?_______ If yes, please describe:
Do you experience Dizziness?______ If yes, how often, and what triggers it?
Do you have high blood pressure?_______ is it being treated? ______ Heart Disease?_____
Family History of Cancer, Heart Disease, or Rheumatoid conditions?______ If yes, please explain.

Do you have chronic pain? _________ If yes, please describe:

Do you have more pain in the morning?__________
and/or stiffness that goes away after you are up for a while? ________
Have you ever had accident/trauma to your neck or spine? ________

Do you see a chiropractor?________
How often do you see your doctor(s)?

Please describe your typical day and list any tasks or physical activities that you are unable to or have trouble doing because of current health problems: ( i.e. can't open jar lids. use back of this page if more room is needed, also list any health concerns ).

You should receive your complete Nutritional/Health analysis
report in two weeks from the time we receive your Questionnaire.
Send $25 check (US dollars) $15 for members, or money order with your questionnaire.