Thank you for taking the time to fill out this form and provide us with details of your health, goals and medical history.

How have you dealt with these concerns in the past?
Do you sleep well?
Do any of these diseases run in your family?
Indicate YES with a check mark
Do you have mercury amalgam fillings?
What percentage of your meals are home-cooked?
Are you currently on a special diet?
Do you feel excessively hungry?
Do you have a poor appetite?
Do you experience more anxiety, depression or anger than you would like?
Do you feel your libido is adequate?