Number of Yes'
Do you smoke (ANYTHING)?
*
Yes
No
Do you exercise less than 3 days each week?
*
Yes
No
Do you have moderate or more levels of stress at work or home?
*
Yes
No
Do you drink less than 8 glasses of water a day?
*
Yes
No
Do you drink bottled, tap water, filtered water from the refrigerator, or from restaurants?
*
Yes
No
Do you have fish at least 2 twice a month?
*
Yes
No
Do you have family history of any heart, liver, or pancreatic disease, autoimmune, cancer?
*
Yes
No
Do you have diabetes?
*
Yes
No
Are you on any medications?
*
Yes
No
Do you get sick more than 3 times a year?
*
Yes
No
Have you ever had any root canals or any extractions?
*
Yes
No
Have you ever had an infection in your gums or teeth?
*
Yes
No
Do you eat sugar at least 3 times a week? Candy, chocolate, soda, etc.
*
Yes
No
Do you eat fast food at least 1 twice a week?
*
Yes
No
Do you take aspirin once a week?
*
Yes
No
Do you have 2 or more cups of coffee a week?
*
Yes
No
Do you have low energy?
*
Yes
No
Have you ever had the flu?
*
Yes
No
Have you ever had Chemotherapy?
*
Yes
No
Are you on ANY natural or prescribed hormone replacement therapy?
*
Yes
No
Do you take 2 vacations a year?
*
Yes
No
Do you consume alcohol twice a week?
*
Yes
No
Do you eat fried food at least once a week?
*
Yes
No
Do you eat leafy green vegetables less than 5 times a week?
*
Yes
No
Do you have neck problems?
*
Yes
No
Do you have chronic headaches or migraines?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have any sort of digestive issues?
*
Yes
No
Have you ever had any surgery that required anesthesia?
*
Yes
No
Are you more than 15 pounds overweight?
*
Yes
No
Do you have trouble going to sleep or staying asleep?
*
Yes
No
Do you experience allergies?
*
Yes
No
Do your wounds tend to take time to heal?
*
Yes
No
Do you have a loss of appetite?
*
Yes
No
Do you have any skin issues?
*
Yes
No
Do you have muscle or joint aches?
*
Yes
No
Do you have less than 4 bowel movements a week?
*
Yes
No
You get the common cold 3 or more times a week?
*
Yes
No
Do you experience any tingling or numbness?
*
Yes
No
Name
*
First Name
Last Name
Email
*
example@example.com
**By providing your phone number, you agree on receiving text from our Center**
Phone Number
*
-
Area Code
Phone Number
Submit
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