Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

Please note this field uses US date format. i.e. mm/dd/yyyy

MM

DD

YYYY

Gender *

Female

Male

Other

Weekly caffeinated tea and/or coffee intake *

0-1

2-5

more than 5

Weekly soft drink intake including caffeinated beverages *

0

1-2

more than 3

Daily water intake (glasses) *

0-3

4-7

8 or more

Weekly servings of dairy including milk & cheese *

0

1-2

3 more more

Weekly alcohol intake *

0-3

4-7

more than 7

Do you have a water filter at home? *

Yes

No

How many bowel movements do you have per week? *

0-5

7-10

More than 10

What blood type are you? *

AB-

AB+

B-

B+

A-

A+

O-

O+

Not sure

Do you experience any of these head-based symptoms? *

Select all that apply.

Headaches/migraines

Dizziness/faintness

Neck tension

Cloudy head

None of the above

Do you experience any of these sinus-based symptoms? *

Select all that apply.

Nasal congestion (stuffy nose)

Allergies (seasonal or daily)

Mucus

Sneezing

Nose blowing

None of the above

Do you experience any of these eye-based symptoms? *

Select all that apply.

Dark circles under the eyes

Bags under the eyes

Itchy eyes

Discharge or watery eyes

Blurred vision

Crusted eyes upon waking

None of the above

Do you experience any of these ear-based symptoms? *

Select all that apply

Itchy ears

Discharge or drainage from ears

Ringing in ears (Tinnitus)

Excessive wax build up

Blocked or muffled hearing

None of the above

Do you experience any of these teeth-based symptoms? *

Select all that apply

Pain in gums or teeth

Bleeding gums

Silver fillings

None of the above

Do you experience any of these mouth-based symptoms? *

Select all that apply

Canker sores

Cold sores (Herpes Virus)

Cracking on lips

Discoloured lips

White film on lips upon waking or after eating

None of the above

Do you experience any of these tongue-based symptoms? *

Select all that apply.

Red dots on tongue

Side of tongue has dents (scalloping)

White, yellow or brown coating on tongue

Cracks or lines on tongue

None of the above

Do you experience any of these gland-based symptoms? *

Select all that apply.

Swollen lymph nodes (neck, armpits or groin)

Difficulty swallowing

Loss of voice

Swollen ankles or hands/wrists/fingers

None of the above

Do you experience any of these breathing-based symptoms? *

Select all that apply

Chest tension

Inability to get enough air in

Chest congestion

Chronic cough

Clearing throat a lot

Voice hoarseness

None of the above

Do you experience any of these weight-based symptoms? *

Select all that apply

Difficulty losing weight

Gaining weight easily

Feeling swollen or puffy

Retaining water

Binge or compulsive eating

None of the above

Do you experience any of these joint/muscle based symptoms? *

Select all that apply.

Pain in joints

Muscle stiffness

Limited range of motion

Muscle weakness

Arthritis

None of the above

Do you experience any of these skin-based symptoms? *

Select all that apply.

Acne

Hair loss

Flushing/hot flashes

Dry, flaky skin

Excessive sweating

Hives or itchiness

Psoriasis, eczema, ringworm or skin rashes

None of the above

Do you experience any of these sleep-based symptoms? *

Select all that apply.

Inability to fall asleep

Can't stay asleep/wake up frequently

Nightmares

Heart racing at night

Night sweats

None of the above

Do you experience any of these energy-based symptoms? *

Select all that apply

Tired upon waking

Daytime or afternoon fatigue

General lack of energy

Apathy

Lack of ambition or drive

None of the above

Do you experience any of these energy-based symptoms? *

Select all that apply.

Hyperactivity (can't sit still)

Restlessness (feeling uncomfortable with quiet)

Tapping feet or shaking legs when seated

Decreased libido or sexual function

None of the above

Do you experience any of these digestive-based symptoms? *

Select all that apply.

Feeling tired after meals (especially lunch)

Gas

Bloating

Belching/burping

Heartburn or indigestion

None of the above

Do you experience any of these digestive-based issues? *

Select all that apply.

Diarrhoea

Constipation

Stomach or intestinal pain

Nausea or vomiting

Stomach sticking out more as day progressing

None of the above

Do you experience any of these mind-based symptoms? *

Select all that apply

Lack of concentration

Easily distracted or lose train of thought

Difficulty making decisions

Brain fog

None of the above

Do you experience any of these mind-based symptoms? *

Select all that apply.

Stuttering or difficulty putting sentences together

Un-coordination or dropping things

ADD/ADHD or learning disabilities

None of the above

Do you experience any of these emotion-based symptoms? *

Select all that apply.

Anxiety

Overwhelm

Irritability

Anger or rage

Dark thoughts

None of the above

Do you experience any of these emotion-based symptoms? *

Select all that apply.

Sad for no reason

Mood swings

Depression

Highly strung

Seasonal Affective Disorder (SAD)

None of the above

Do you experience any of these immunity-based symptoms? *

Select all that apply.

Frequent colds (more than 2-3 per year)

Allergies (environmental or non-fatal food sensitivities)

Pneumonia in the last 12 months

Diagnosed disease

Unexplained illness

None of the above