1.
Do you have a primary health concern or affliction that you know of?
2.
If you answered 'yes' to the previous question and you know the name of your affliction; please enter it here.
3.
How long have you been suffering from symptoms?
1 week or less
1 - 6 weeks
Several months
More than a year
Answer 1
1 week or less
1 - 6 weeks
Several months
More than a year
4.
Have you ever had surgey?
5.
(Female) Have you ever been on a contraceptive pill?
6.
Do/did you eat meat or dairy products?
7.
Are you currently a vegan? If so, for how long?
Yes
No
Less than a month
Yes
No
Several months
Yes
No
More than a year
Yes
No
8.
Do you purchase organic produce?
9.
List the typical foods you eat on a daily and weekly basis.
Use commas to seperate items on your list.
10.
Do you eat out regularly?
11.
Do you eat soy products?
12.
Do you ever eat flaxseed, beets or carrots?
* 13.
Are you currently taking any prescription medication?
14.
(Optional) Please list all of the prescription medications you are currently taking.
15.
Do you have anyallergies?
16.
Do you have any respitory disorders (not mentioned above)?
17.
Have you ever had cancer?
* 18.
Please enter the email address where we will send your free gift.