Health Screening Questionnaire

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Health Screening Questionnaire
Check all that apply!

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Name *
E-mail Address *
Country *
IMMUNE, VASCULAR & INFLAMMATION PATHWAYS
	Do you seem to "catch everything" that goes around?
	Do you have inflammatory conditions like arthritis in your family?
	Do you have digestive problems? (indigestion, hearburn, gassiness etc.)
	Do you have elimination problems? (constipation, diarrhea, irregularity)
	Do you have high blood pressure in your family?
ANTIOXIDANT PATHWAYS
	Do you eat less than 5 servings of fruits and vegetables a day?
	Do you drink sugar-sweetened soda?
	Do you have cancer, diabetes or heart disease in your family?
	Are you under a lot of stress, either physical or emotional?
	Do you feel you are showing signs of premature aging?
	Do you spend a lot of time in the sun, particularly during peak sun hours?
DETOXIFICATION PATHWAYS
	Do you eat a lot of fast food?
	Do you drink diet sodas or artificially sweetened beverages?
	Do you eat conventionally-grown (non-organic) fruits, vegetables or meat/fish?
	Are you exposed to household cleaners, paint/copier/dry-cleaning fumes, fingernail polish/remover or other cosmetic fumes (like synthetic perfumes or hairsprays)?
	Do you use deodorants containing aluminum?
	Do you live in or near a large urban area?
	Do you often feel tired and struggle to get through your day?
	Have you moved into a new house or office building in the last year?
	Have you bought a new car in the last -12 months?
	Have you been exposed to new carpeting or painting in the last 6 months?

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Our purposes are educational and informational only and we assume no responsibility for the correct or incorrect use of our information. This information has not been evaluated by the Food and Drug Administration. Any information we provide is not used to, nor are they intended to, diagnose, treat, cure or mitigate any specific health problem. Anyone with any health complaint should seek the care and consultation of an appropriate licensed health practitioner. No attempt should be made to use any information we provide as a form of treatment for any specific condition without the approval and guidance of a physician.