Number of Yes'
Do you experience an upset stomach twice a week?
*
Yes
No
Do you experience bloating or gas twice a week?
Yes
No
Do you experience stress on a weekly basis?
Yes
No
Do you worry on weekly basis?
Yes
No
Do you exercise 2-3 times a week?
Yes
No
Do you eat steamed green vegetables on a daily basis?
Yes
No
Do you get less than 7 hours of sleep weekly?
Yes
No
Do you struggle with weight loss or maintaining a healthy weight?
Yes
No
Do you experience a sense of hunger after eating a meal?
Yes
No
Do you experience constipation weekly?
Yes
No
Do you have loose bowel movements weekly?
Yes
No
Do you take antacids?
Yes
No
Have you had any piercings or tattoos done anywhere?
Yes
No
Do you currently have or had at any point more than 2 fillings in your mouth or do you have any current dental infections or cavities?
Yes
No
Do you take any medications for digestions?
Yes
No
Are you lactose intolerant?
Yes
No
Do you have less than 1 bowel movement a day?
Yes
No
Does your stool vary from watery to hard pellets or anything in between?
Yes
No
Have you recently lost weight from no obvious reasons?
Yes
No
Do you experience colds or flus on a yearly basis?
Yes
No
Do you suffer from allergies?
Yes
No
Do you feel tired or have less energy after eating?
Yes
No
Does your stool ever change colors?
Yes
No
Do you ever experience dry mouth?
Yes
No
Do you ever experience a metallic taste in the mouth?
Yes
No
Do you have bad breath?
Yes
No
Do you consider yourself a stress eater?
Yes
No
Do you take time to chew your food?
Yes
No
Do you experience memory loss?
Yes
No
Do you have more than 2 alcoholic beverages weekly?
Yes
No
Do you smoke or do tobacco?
*
Yes
No
Do you watch TV when you eat?
Yes
No
Do you experience weekly mood changes?
Yes
No
Have you ever had a round of antibiotics of any kind in your life?
Yes
No
Do you drink coffee at least once a week?
Yes
No
Do you eat any kind of chocolate or candy at least twice a month?
Yes
No
Do you have sugary drinks or add sugar to anything at least twice a month?
Yes
No
Name
*
First Name
Last Name
Email
*
example@example.com
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Phone Number
*
-
Area Code
Phone Number
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