| EMAIL: |
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| NAME: |
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| ADDRESS: |
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| CITY: |
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| STATE: |
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| ZIP: |
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| HOME PHONE: |
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| CELL PHONE: |
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| WORK PHONE: |
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| AGE: |
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| WEIGHT: |
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| HEIGHT: |
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| BIRTH DATE: |
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| OCCUPATION: |
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| 1ST MAJOR AILMENT: |
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| 2ND MAJOR AILMENT: |
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| 3RD MAJOR AILMENT: |
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| 4TH MAJOR AILMENT: |
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| CURRENT MEDICATIONS: |
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| HISTORY OF ILLNESS AND TREATMENT: |
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| ALLERGIES/SENSITIVITIES: |
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| HAVE YOU EXPERIENCED A MAJOR LOSS OR TRAUMA IN THE PAST 5 YEARS?: |
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STUBBORN WEIGHT |
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Crave refined carbohydrates |
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Frustrating stubborn weight |
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History of low-calorie diets |
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Fluid retention |
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History of birth control pills |
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History of Hormone Replacement Therapy |
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High protein diets |
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Lack of willpower |
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Can't lose weight regardless of exercise |
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MENSTRUAL (FEMALE ONLY) |
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PMS |
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Irregular periods |
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Ovarian cysts |
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Heavy bleeding during menstruation |
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Fibrocystic breasts |
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MENOPAUSE (FEMALE ONLY) |
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Hot flashes |
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Night sweats |
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Vaginal dryness |
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Leaky bladder |
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Frequent urination at night |
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Bone loss/osteoporosis |
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BLOOD SUGAR |
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Diabetic |
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History of diabetes in family |
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Craving sweets, refined carbohydrates |
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Tired at 3:00 p.m. (afternoon) |
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Acne and/or skin problems |
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Lack of energy |
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Depression |
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Anxiety |
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Numbness or tingling in finger tips or toes |
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Eyesight getting worse |
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Excessive thirst |
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Get irritable or shaky when hungry |
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THYROID |
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Fatigue |
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Intolerance to cold |
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Cold hands or feet |
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Sluggish elimination |
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Constipation |
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Lack ability to concentrate |
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Hair loss |
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High cholesterol |
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Rigid fingernails (vertical up and down) |
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Brittle fingernails |
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Weight (sluggish) |
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DIGESTION/KIDNEY |
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Do you drink 1/2 of your weight in ounces of water every day? |
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Acid reflux |
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Bad breath |
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High blood pressure |
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High cholesterol |
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Stomach bloats |
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Skin problems |
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Burning feet |
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Pain between shoulder blades |
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Intestinal gas |
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Irritable Bowel Syndrome |
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Coated tongue (white film) |
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Indigestion |
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History of antibiotics |
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Toe nail fungus |
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Headaches or migraines |
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Painful joints |
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Right shoulder pain or tightness |
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Itchy private parts |
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PROSTATE (MALE ONLY) |
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Urination difficulty or dribbling |
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Urinate frequently at night |
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Enlarged prostate |
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ADRENALS |
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Intolerant to cold |
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Anxious, anxiety attacks |
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Heart palpitations |
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Sad, irritable or depressed |
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Overwhelmed |
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Confusion |
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Just not myself |
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I am exhausted in the morning |
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Tired when I wake up |
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Use caffeine to jump start throughout the day |
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I have gained weight compared to last year |
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Forgetful, fuzzy-minded, absentminded |
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Bloating and/or gas |
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Bouts of diarrhea |
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Decrease interest in sex |
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Dry skin |
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Dry, brittle hair |
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Hair thinning |
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Out of breath when walking up stairs |
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Dizziness |
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Excessive facial hair (female) |
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Fatigue during the day |
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Difficulty getting out of bed in the morning |
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Stiff and painful joints (especially in the morning) |
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Difficulty falling asleep |
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Difficulty staying asleep |
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Arthritis |
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Nervousness |
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Fluid retention |
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Swollen ankles |
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Allergies |
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Asthma |
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Crave salt--put extra on food, crave chips, pretzels |
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Muscle cramps, worse during exercise |
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Dull pain in chest or radiating in left arm |
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Irregular periods |
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Hot flashes |
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Night sweats |
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PMS (cramps, nausea, breast tenderness, irritability) |
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DEMANDS ON YOUR BODY |
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Do you eat a good, balanced breakfast? |
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Do you eat 5 or more fruit and vegetables a day? |
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Do you minimize simple carbs and sweets? |
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Do you mininmize alcohol intake? |
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Do you exercise 4 or more times a week? |
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Do you get 7-8 hours of sleep per night? |
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Do you rest when you are feeling run-down or fatigued? |
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Do you feel you make adequate time for your needs? |
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Do you take some time for yourself every day? |
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Do you try to minimize toxins and processed foods in your diet? |
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Do you try to minimize stress in your life? |
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Do you take high-quality, pharmaceutical-grade nutritional supplements with essential fatty acids? |
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Do you have a support system of friends that you can share things that bother you and support each other? |
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Does your family understand what you are going through? |
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Do you work 40 hours a week? |
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