YHPharmacy Questionnaire

Personal & Confidential Antioxidant Health Assessment
Health: Education, Income, Discipline Disease: Inflammation & Oxidative Stress

Prevention through Nutrition: “The amount of antioxidants that you maintain
in your body is directly proportional to how long you will live.” Dr. Richard Cutler NIH

Please enter a valid phone number.Format: (000) 000-0000.

Supplementation Assessment

Besides your number one health concern, please select any additional concerns you may have:

Indigestion/gas after eatingFeel too full after eating, bloatingSleepy or low energy after eatingUncomfortable or adverse reactions after eatingDiet consists of mostly processed and cooked foodThe need to eliminate soon after eatinglarge bowel movements daily

Bones ache, feel tender or soreUpper or lower back painPain when sitting down or walkingTeeth are prone to decayJoint swelling, pain or stiffness involving one or more areas (fingers, hands, wrists, elbows, shoulders, toes, arches, feet, ankles, knees or ankles)A routine exercise program, like daily walking, causes your knees to swell or hurtInjure, strain or sprain easilyMuscles stiff, sore, tense and/or achySpecific points on the body feel sore when pressedMuscle cramps or spasms/twitches

Section 12 - FEMALE ONLY (Hormones)

Indicate which conditions apply only if they occur within 14 days prior to and two days after
menstrual period: (Menopausal women skip to Part B)

Nutritional Questionnaire