Date:
Email address:
First Name:
Last Name:
Shipping Address:
City:
State: AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - Washington DC DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Not USA
Zip:
Gender: Female Male
Age:
1. Foul smelling stools - worse in afternoon and evening Yes No Sometimes
2. Itching around the anus, especially at night Yes No Sometimes
3.Grinding teeth during sleep Yes No Sometimes
4. Have taken a broad-spectrum antibiotic Yes No Sometimes
5. Alternating constipation diarrhea Yes No Sometimes
6. Whitish coating on tongue Yes No Sometimes
7. Eyes overly sensitive to sunshine or bright light Yes No Sometimes
8. Episodes of dizziness or blacking out upon standing Yes No Sometimes
9. Wake too early in the morning, such as 3 or 4 am Yes No Sometimes
10. Cold hands and feet Yes No Sometimes
11. Temperature less than 98.6 F Yes No Sometimes
12. Gain weight easily or hard time losing it Yes No Sometimes
13. Fats / greasy foods cause nausea or headaches Yes No Sometimes
14. Skin peels on soles of feet Yes No Sometimes
15. Dandruff or itchy scalp Yes No Sometimes
16. Gas, belching, or burping immediately after meals Yes No Sometimes
17. Abdominal bloating or distension Yes No Sometimes
18. Nausea after taking supplements Yes No Sometimes
19. Stomach pain relieved by drinking milk Yes No Sometimes
20. Hot or spicy foods cause stomach irritation Yes No Sometimes
21. Depression Yes No Sometimes
22. Dry eyes or frequent chapped lips Yes No Sometimes
23. High blood pressure or clogging of arteries Yes No Sometimes
24. Ancestry that is ¼ or more Celtic Irish, Scandinavian, Native American, Welsh, or Scottish Yes No Sometimes
25. Family history of alcoholism, depression, suicide, schizophrenia, or other mental illness Yes No Sometimes
26. Winter depression that lifts or lightens in the sunny springtime Yes No Sometimes
27. I have hard, difficult to pass bowel movements once a day or less Yes No Sometimes
28. I use garden chemicals or treat with insecticides or have exposure to toxins in the workplace Yes No Sometimes
29. I frequently experience one of the following: headache, sore throat, muscle aches, colds or flu Yes No Sometimes
30. I have been on prescription medications for some time Yes No Sometimes
31. My stool frequently has a foul odor or I often have bad breath or body odor Yes No Sometimes
32. I have one or more of the following: skin tags or rashes, sneezing attacks, excessive mucous Yes No Sometimes
Additional Questions for Females
33. Loss of scalp hair Yes No Sometimes
34. Oily skin, acne Yes No Sometimes
35. Increased facial hair Yes No Sometimes
36. Low sex drive Yes No Sometimes
37. Vaginal dryness Yes No Sometimes
38. Memory lapses or foggy thinking Yes No Sometimes
39. PMS Yes No Sometimes
40. Painful or lumpy breasts Yes No Sometimes
41. White spots on fingernails Yes No Sometimes
42. Night sweats Yes No Sometimes
43. Hot flashes Yes No Sometimes
44. Painful intercourse or vaginal dryness Yes No Sometimes
45. Tender breasts Yes No Sometimes
46. Water retention or puffiness Yes No Sometimes
47. Heavy Menstruation Yes No Sometimes
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