IMMUNE SYSTEM
Do you have more than one sore throat or cold a year?
Do you have sore throats, colds or bouts with flu lasting longer than 4 days?
Do you have recurring infections?
Are you frequently tired?
Do you have a hard time getting up in the morning?
Do you get light-headed when hungry?
Do you get headaches frequently?
Do you ever feel dizzy or off balance?
Does eating improve the way you feel?
Do you find yourself bingeing at times?
Do you seek stimulation from coffee, alcohol, candy, etc?
Does it seem that you are thirsty overly much?
Do you have high energy soon after consuming sweets?
Are you tired or sleepy a while after consuming sweets or starches?

RESPIRATORY SYSTEM
Are you often short of breath with moderate exertion?
Do you breathe heavily after climbing a set of stairs?
Do you tend to get a side ache when running or from other physical exertion?
Do you smoke tobacco?
Do you smoke 1/2 pack of cigarettes per day or more?

ALLERGIES
Do you have respiratory allergies (ex. pollen, fumes)?
Do you have or suspect you have food allergies?

CIRCULATORY SYSTEM
Is your heartbeat irregular?
Does your heart rate become rapid with only slight exertion?
Does your heart beat flutter at times?
Have you had a heart attack?
Have you had a stroke?
Are your hands and/or feet often cold?
Do your ankles, feet or hands swell (water retention)?
Do you sometimes have tingling, burning or numbness in your hands, arms, legs or feet?

NERVES & BRAIN
Do you have frequent nervous twitches?
Do you feel seriously stressed by your circumstances?
Are you a nervous person?
Do you often feel tense?
Do you at times feel depressed?
Are you anxious about possible events?
Do you get irritated easily?
Are you forgetful or confused?
Do you have a hard time concentrating?
Are you in an electronic field very much of the time (ex. on a computer, near utility wires, etc.)?

WEIGHT PROBLEMS
Are you overweight?
Are you excessively overweight?
Are you not really overweight, but you'd like to lose a few pounds?
Is it difficult for you to keep your weight down where you'd like it?
Are you underweight?
Do you have or think you might have an eating disorder?
Is it hard to gain weight even though you are eating well?
Do you walk briskly or exercise aerobically for at least 20 minutes LESS than 3 times a week?

DIGESTIVE SYSTEM
Do you have frequent indigestion?
Do you have stomach gas, feel bloated, or belch after meals or snacks?
Do you get stomach aches?
Do you have an intestinal gas problem (flatulence)?
Are you sometimes constipated (bowels hard to move)?
Do your bowels move less than 2 times a day?
Do your bowels move less than once a day?
Do your bowels move more than 3 times per day?
Do you have frequent diarrhea (loose watery stools)?
Do you commonly have an excessive urgency to move your bowels?
Does your rectum itch occasionally?
Does food take more than 15 hours to pass through?
Do your stools have an overly foul odor?
Do your stools have a light color and float?
Is your stool sticky (leaving anal residue) frequently?
Do fiber foods bother you?
Do you drink more than 2 cans of soda pop per week?
Do you eat sugar, candy, ice cream, baked goodies, etc?
Do you often consume items with Nutrasweet™ / Aspartame™ in them?
Do you consume less than one cup of raw vegetables and one cup of raw fruits daily?
Do you consume more than 4 cups of dairy milk per week?
Do you eat more than 4 servings of cheese, yogurt, sour cream and/or ice cream per week?
Do you try to eat a concentrated protein food (meat, fish, milk, cheese, eggs, nuts, seeds) at every meal?
Do you consume 'red' meat (beef, pork, lamb, venison, etc) more than 3 times per week?
Do you eat processed meats (wieners, sausage, pepperoni, baloney, etc)?
Do you eat more than 3 servings a week of white flour products (white bread, rolls, pasta, etc)?
Do you eat less than 3 servings per week of whole grain foods (whole wheat bread, brown rice, oatmeal, barley, etc)?
Do you eat products made from soybeans more than once a week?
Do you regularly consume more than one of these foods in the same meal: meat, fish, cheese, egg, cereal, bread, pasta, rice, fruit/fruit juice, sweets?
Do you drink beverages with meals?
Do you use salt or salted foods?
Do you consume 'junk' foods and 'junk' snacks regularly?
Do you skip breakfast?
Do you snack between meals and/or in the evening?
Do you commonly eat late in the evening?
When you eat a meal, do you eat until you are stuffed?
Do you cook some of your food in a microwave oven?

MINERALS
Do you get leg cramps?
Do you have calcium deposits?
Do you have soft or brittle bones?
Do you drink and cook with unfiltered tap water?
Do you bathe and/or shower in unfiltered tap water?
Do you drink less than 40 oz of pure water per day?

DENTAL PROBLEMS
Have you had a lot of dental caries & cavities?
Do you have silver fillings in your teeth?
Do you have sore or sensitive gums?
Do you ever have jaw popping or pain in the jaw?
Is your bite irregular?
Do you chew more on one side of the mouth?

URINARY SYSTEM
Do you feel the need to urinate more frequently than normal?
Do you have trouble initiating urination?
Do you have trouble expelling urine thoroughly?
Do you lose urine due to physical effort, such as sneezing, coughing, lifting, or climbing stairs?
Can you stop urine flow during urination?
Do you lose a large volume of urine during unwanted urination?
Do you feel urine pressure before unwanted urination?
Do you lose urine before you reach the toilet?
Do you feel complete bladder emptiness after urination?

FEMALE CONDITIONS
Do you have PMS problems?
Are you menopausal or post menopausal?
Have you had vaginal yeast problems?
Have you had swelling or lumps in a breast?
Have you given birth to children?
Are you currently pregnant or nursing?

SEXUAL PERFORMANCE (male or female)
Do you have a diminished sex drive?
Is the duration of your sexual arousal insufficient?

EYES
Are there any ruptured blood vessels in the whites of your eyes?
Are your eyes abnormally sensitive to light or wind?
I have difficulty reading fine print
I get headaches, tired eyes and/or burning after reading
I have problems driving at night
I see spots, floaters, or flashes of light
I have a family history of 'lazy eye'
My eyes get red or irritated
I have 'dry' eyes
The sun hurts my eyes
I use a tanning bed
I have cataracts
I have had a sudden loss of vision
I have had a growth on my eye

SKIN PROBLEMS
Do you bruise easily?
Do cuts & bruises heal slowly?
If you cut yourself, is the bleeding slow to stop?
Do you have excessively dry skin and/or hair, and/or brittle nails, and/or dry mouth?

OTHER CONCERNS
Are you weak muscled?
Do you have trouble falling asleep or sleeping deeply?
Do you have a halitosis ('bad breath') problem?
Do you have periods of hyperactivity?
Do you drink more than one cup of coffee per day?
Do you drink alcoholic beverages more than 2 times per week?
Do you drink more than 2 alcoholic drinks in a day or evening?
Do you have a serious medical condition for which you are currently under a physician's treatment?
Are you currently taking any medications?

Whiplash Injury:
a few months ago
about a year ago
about 3 years ago
about 10 years ago
about 30 years ago or more

I don't feel as vibrant and energetic as I would like.
I understand that improving my health is important for the rest of my life.

NUTRITIONAL SUPPLEMENTS
Do you take vitamins regularly?
Do you take 500 mg or more of Vitamin C daily?
Do you take Vitamin E regularly?
Do you take other antioxidants regularly?
Do you take B-vitamins or a multi-vitamin regularly?
Do you take extra calcium regularly?
Do you take extra magnesium regularly?
Do you take a 'trace mineral' product regularly?
Do you consume 'super foods' (ex. spirulina and/or cereal grasses) daily?
Do you take herbal products regularly?
Do you take supplemental enzymes regularly?
Do you consume foods or supplements rich in Omega 3 fatty acids regularly?