Please help us to serve you better by completing this survey. It should take around 5 minutes to complete.

1. Name *
2. Email Address *
3. Phone Number *
4. Blood group
5. Height
6. Weight
7. Rh Factor PositiveNegative
8. Do you suspect that something in your body is out of balance? YesNo
9. Do you think your "problem" is linked to stress? YesNo
10. Are you experiencing minimal weight loss despite trying to exercise and eat well? YesNo
11. Are you often tired and sluggish when you wake up in the morning? YesNo
12. Do you experience lack of energy several days a week? YesNo
13. Do you sometimes experience brain fatigue or memory loss? YesNo
14. Do you have or suspect a thyroid problem YesNo
15. Do you often feel frozen? YesNo
16. Do you snore when you sleep? YesNo
17. Do you sleep less than 8 hours per night? YesNo
18. Do you have trouble getting your brain to relax at bedtime? YesNo
19. Do you breathe through your mouth as soon as you exert yourself? YesNo
20. Do you work shifts that require you to stay up late? YesNo
21. Do you experience mood swings? YesNo
22. Do you often turn to food or sugar for comfort or as a reward? YesNo
23. Do you have sugar cravings, chocolate cravings or other cravings several days a week? YesNo
24. Do you regularly eat or drink foods with a lot of sugar, white flour or dairy products? YesNo
25. Do you often eat very quickly? YesNo
26. Do you feel bloated at times? YesNo
27. Do you experience constipation? YesNo
28. Do you experience pain or a lot of stiffness in your body? YesNo
29. Do you suspect that your pain is linked to high levels of inflammation? YesNo
30. Do you frequently become ill when starting intense workout? YesNo
31. Are you currently taking any medications that are directly linked to anxiety/depression? YesNo
32. Are you currently taking any medications for your blood pressure? YesNo