Date_____________

Name __________________________________________ D.O.B.__________________

Address _________________________________________________________________
City ______________________ State ________ Zip Code __________
Phone # ________________________ Cell # _________________________
E mail __________________________________________________________________
Who referred you _________________________________________________________

*Is the shipping address same as above? Yes No If not, then fill in below.

Address ________________________________________________________________
City ____________________ State ______ Zip Code __________

Reason for visit (prioritized):

1.______________________________________________________________________
2.______________________________________________________________________
3.______________________________________________________________________

On a scale of 1-10, 10 being the best, how would you rate your current health? _____________

Have you ever tried alternative healthcare? Yes No

What are your Health Goals? ______________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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 Supplements/Medications:
Do you take any supplements? Yes No
If so, what, how often and why? ___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Do you take any OTC medications routinely (such pain reliever or allergy medicine)? Yes No
If so, what and how often? ______________________________________________________
Do you take prescription medications (prescribed by a licensed medical professional?) Yes No
If so, what and how often? _______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Family History
What have your parents been diagnosed with?

Mother: ______________________________________________________________________
______________________________________________________________________________
Father: _______________________________________________________________________
______________________________________________________________________________
Siblings: ______________________________________________________________________
______________________________________________________________________________

Medical History

Last visit to Medical Doctor? ____________

Have you received any diagnoses from licensed medical professionals? Yes No
If so, what and when? ____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Have you had any surgeries Yes No If so, what and when?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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Childhood Illnesses? _____________________________________________________________
Have you taken antibiotics in the last year? Yes No How many times? _____________

Why did you take them? ___________________________________________________

Are your present health problems something new? Yes No

Do you have long term problems you have been dealing with? Yes No

Please explain __________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

Women

Last cycle _______________ Are you currently missing cycles? Yes No

Are your cycles heavy? Yes No Are you interested in Bio Hormone? Yes No

Are you post-menopausal? Yes No If yes, at what age did you enter menopause? _________

What were the characteristics of your menopausal experience? __________________________

______________________________________________________________________________
Do you currently use Hormone Replacement or Hormonally-based Contraception? Yes No
Are you now, or in the near future, planning to become pregnant? Yes No
Is your menstrual cycle regular? Yes No Longer than 28 days? Yes No Shorter? Yes No
Is your flow longer or shorter than 5 days? ___________________________________________
Do you have cramps or clotting? Yes No
Would you describe the color of your menses as bright red, dark purple, or brown?
______________________________________________________________________________
Do you experience PMS, cyclical headaches, or cravings? Yes No

Men:

When was the last date of your PSA? _________ Problems w/ urination Yes No

Young Adults or Children: (Circle what applies)

Fatigue Concentration ADD ADHD Stomach Pain

Rev 06/09, v4.10-4.41

 Nutritional data:
How many ounces of water/day? ________ What kind? ________________________________
What other beverages and how much? ______________________________________________
Do you use artificial sweeteners? Yes No If so, which ones? ____________________________
How often and in what? __________________________________________________________
Do you eat breakfast? Yes No If so, what? ______________________________________
______________________________________________________________________________

How much of the following do you consume? (Example: 1D = 1/day, 2W = 2/week, 3M = 3/month)

Fresh fruit: _________ Raw vegetables: _________ Fermented foods: ________

Fast foods: __________ Meat: __________ Eggs: _________ Dairy: _________

What do you crave? _____________________________________________________________

What foods do you dislike the most? ________________________________________________
Why? _________________________________________________________________________
______________________________________________________________________________

Timing:
What is the first thing you do when you get up in the morning? __________________________
______________________________________________________________________________
What time do you eat your first meal? ____________ Last meal? _________________________
Which meal is your largest of the day? ______________________________________________
Describe a typical largest meal. ____________________________________________________
______________________________________________________________________________

Movement:
Do you exercise/move/participate in fun sweaty activity? Yes No
If so, what and how often? ________________________________________________________
______________________________________________________________________________
Do you look forward to it? Yes No
How do you feel when you are finished? _____________________________________________

Sleep:
What time do you go to bed? _________________ How long do you sleep? ________________
Do you wake often? Yes No
If so, why and at what time(s)? ____________________________________________________
Do you feel rested when you wake up for the day? Yes No
Do you have pain when you first get up? Yes No

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If so, where? ___________________________________________________________________
______________________________________________________________________________
Does it go away upon moving? Yes No

Eliminations:
Do you have daily bowel eliminations? Yes No If yes, how many per day? ________
If no, please describe your elimination pattern. _______________________________________
______________________________________________________________________________

Please indicate the most descriptive number(s) of your elimination(s) using the Bristol Stool
Chart provided.
BSC Type # _______________ Color ________________________________________

NUTRIENT SURVEY QUESTIONNAIRE

Rev 06/09, v4.10-4.41

INSTRUCTIONS: Please read the questions below and put a check (DO NOT USE YES or NO ANSWERS) in
front of the questions that most accurately describe you and the symptoms you normally experience. Many of the
questions will seem similar to you and are included to assure accuracy of test results.

______ 1. Do you have trouble judging distances while driving at night?

______ 2. Do you have little bumps on your upper arm?
______ 3. Do your eyes ever burn or itch?
______ 4. Do you have poor immunities, getting sick frequently?
______ 5. Is acne or tearing cuticles a problem for you?
______ 6. Have you gotten a new wart(s) in the last six months?
______ 7. Do you pass blood clots or hemorrhage during your menstrual period? If yes, please answer
with two checks.
PART 1 _______
______ 1. Do you have a general lack of energy?
______ 2. Do your lips crack, chap, or feel dry frequently?
______ 3. Do you feel tired when you get up in the morning?
______ 4. Do your feet smell when you take off your socks?
______ 5. Do you eat chocolate or drink more than 2 cups of coffee daily?
______ 6. Females - Do you currently use synthetic estrogen or birth control pills?
______ 7. Do you have pucker marks on your upper lip?
PART 2 _______
______ 1. Do you bruise easily?
______ 2. Do your gums bleed when you brush or floss?
______ 3. Do you have varicose veins?
______ 4. Do you ever get nosebleeds?
______ 5. Do you smoke cigarettes?
______ 6. Do you have any bruises right now?

PART 3 _______
______ 1. Do you ever get leg cramps, "Charlie horses" or menstrual cramps?
______ 2. Do you have muscle spasms?
______ 3. Do you feel nervous or irritable at times?
______ 4. Do you ever break bones?
______ 5. Do you have difficulty sleeping well?
PART 4 _______
______ 1. Do you ever experience shooting pains in your left arm?
______ 2. Have you ever had a heart attack or a stroke?
______ 3. Do your hands or feet fall asleep easily?
______ 4. Do you ever have blood clots or varicose veins?
______ 5. Females - Are you infertile, on birth control pills or menopausal?
______ 6. Males - Have you lost your sex drive?
______ 7. Do you have high cholesterol, triglycerides, or blood pressure?
PART 5 _______
______ 1. Do you have problems with water retention?
______ 2. Have you ever had kidney stones?
______ 3. Do you get occasional sores in your mouth?
______ 4. Females - Is Premenstrual Tension a problem for you?
______ 5. Do you experience motion sickness easily?
______ 6. Do you have a high cholesterol level?
PART 6 ______

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______ 1. Do you generally have a poor appetite?
______ 2. Are you anemic?
______ 3. Are you a vegetarian, seldom eating flesh foods?
______ 4. Do you feel fatigued or depressed frequently?
______ 5. Do you have poor digestion?
______ 6. Do you feel as if your concentration and memory are failing?
______ 7. Is your tongue sore sometimes?
PART 7 _______
______ 1. Do you smoke cigarettes daily?
______ 2. Do you catch infections frequently?
______ 3. Do you have allergies?
______ 4. Have you ever had cataracts?
______ 5. Do your wounds, cuts, and bruises heal slowly?
______ 6. Do you have loose teeth or gums that bleed when you brush or floss?
______ 7. Do you get frequent sore throats?
PART 8 _______
______ 1. Do you have dark circles under your eyes?
______ 2. Do you ever experience rectal itching?
______ 3. Do you grind your teeth at night or sometimes pick your nose?
______ 4. Do you have any house pets?
______ 5. Have you ever traveled to a "Third-World" country?
______ 6. Have you ever eaten raw fish (sushi) or raw meat?
______ 7. Do you ever eat pork products - ham, bacon, pork chops, pork ribs?
PART 9 _______
______ 1. Do you burp after eating?
______ 2. Do you have bad breath frequently?
______ 3. Do you need to use antacids occasionally?
______ 4. Do you sometimes feel bloated after a meal?
______ 5. Do you frequently have gas?
______ 6. Do you have a low appetite level?
______ 7. Do you occasionally experience heartburn?
PART 10 _______
______ 1. Do you have leg cramps, "Charlie horses" or menstrual cramps?
______ 2. Are you suffering from gum disease?
______ 3. Do you have arthritis or osteoporosis of any kind?
______ 4. Do you have achy or swollen joints?
______ 5. Turn your neck from side to side--do you hear a cracking/scraping noise?
______ 6. Do you ever have muscle spasms?
PART 11 _______
______ 1. Do you feel tired much of the time?
______ 2. Do your fingernails split or peel horizontally?
______ 3. Do you have dark circles under your eyes much of the time?
______ 4. Are you just as tired when you wake up as when you went to bed?
______ 5. Have you ever been told you were anemic?
______ 6. Do your cheeks seem to have lost a natural, rosy color?
______ 7. Do you drink more than 2 cups of coffee or black tea daily?
PART 12 _______
______ 1. Do you have an irregular heartbeat?
______ 2. Do you need to use laxatives or experience diarrhea frequently?
______ 3. Do you have weak muscles or do your muscles cramp?
______ 4. Do you use Licorice Root herb daily?
______ 5. Do you occasionally feel slightly shaky, lightheaded, "spacey", or "on edge"?
______ 6. Do you have sluggish intestines with gas accumulations?
______ 7. Do you use diuretics (drugs, not herbs)?
PART 13 _______
______ 1. Do you have little white specks on your fingernails? (If yes, two checks)
______ 2. Do you heal slowly when you cut yourself?
______ 3. If you are male, do you have trouble voiding completely?
______ 4. If you are male, do you urinate frequently during the day or several times at night?
______ 5. Do you have diabetes?
______ 6. Have you had a loss of sense of taste, smell, or hearing?
PART 14 _______
Rev 06/09, v4.10-4.41
______ 1. Do you sometimes experience constipation (less than one bowel elimination a day)?
______ 2. Do the bottoms of your feet hurt when you first get out of bed in the morning?
______ 3. Do you take a fiber supplement daily? Check this IF THE ANSWER IS NO.
______ 4. Do you occasionally have intestinal gas or sharp pain(s) in your abdomen (below your waist)?
______ 5. Do you have loose stools or diarrhea frequently?
______ 6. Are your stools either watery or quite hard?
PART 15 _______
______ 1. Do you sleep poorly or feel fatigued much of the time?
______ 2. Do you use alcohol and/or dairy products on a daily basis?
______ 3. Do you ever get muscle tremors, leg cramps, or muscle spasms?
______ 4. Are you menopausal or post-menopausal or do you have osteoporosis or kidney stones?
______ 5. Are you ever bothered by nervous twitches or "tics" or feel very nervous at times?
______ 6. Do you have heart disease or cardiac arrhythmias?
______ 7. Do you feel stressed or anxious much of the time?
PART 16 _______
______ 1. Does you tongue or mouth get sore occasionally?
______ 2. Do you have Herpes of the mouth or genitalia?
______ 3. Do you ever get canker sores or cold sores?
______ 4. Do you ever get unexplained skin rashes, fungus infections, vaginitis or "jock itch", or
recurring kidney/bladder infections?
PART 17 _______
______ 1. Do you have stomach or duodenal ulcers?
______ 2. Do you have a hiatal hernia or do you experience a burning sensation in the throat or chest when you lie down?
______ 3. Is it hard to eat a meal without feeling an upset stomach?
______ 4. Do you feel nauseated when you are nervous or hungry?
______ 5. Do you sometimes have heartburn?
______ 6. Do you experience pain (s) in your stomach for which you use antacids occasionally?
PART 18 _______
______ 1. Do you have trouble digesting fats?
______ 2. Do you have a high cholesterol or triglyceride level? If yes, please answer with two checks.
______ 3. Do you have heart trouble?
______ 4. Do you have high blood pressure?
PART 19 ________
______ 1. Do you have cold hands & feet?
______ 2. Are you extremely uncomfortable when it is quite cold?
______ 3. Would you like to be able to take a nap in the middle of the afternoon?
______ 4. Do your fingers tremble when you hold them straight out?
______ 5. Is your hair dry & brittle or thin?
______ 6. Does your heart beat very fast after exerting yourself?
______ 7. Do you gain weight easily?
______ 8. Are you uncomfortable when it is very hot?
PART 20 _______
______ 1. Do you get extremely thirsty frequently?
______ 2. Do you have mood swings, feeling fine one moment and "down in the dumps" the next?
______ 3. When you cut yourself, do you heal very slowly?
______ 4. Do you feel that you urinate large amounts?
______ 5. Have you ever been diagnosed as having diabetes? (If YES, put two checks)
______ 6. Does your breath ever smell sweet?
PART 21 _______
______ 1. Do you feel like you often have mood swings? (If YES, put two checks)
______ 2. Do you have a problem with motion sickness?
______ 3. Do you feel like you have low energy much of the time?
______ 4. Do you crave sweets, cigarettes, coffee or cola drinks between meals?
______ 5. Do you have low blood pressure?
______ 6. Do you often feel shaky or confused?
______ 7. Do you have low blood sugar or hypoglycemia? (If YES, put two checks)
______ 8. Do you have a weight problem?
PART 22 _______

Rev 06/09, v4.10-4.41

______ 1. Are your hands and feet often cold or do they "fall asleep" easily?
______ 2. Have you had a stroke or heart attack? If yes, please answer with two checks.
______ 3. Are you ever aware of your heart beating irregularly?
______ 4. Do you feel breathless when you exert yourself?
______ 5. Do your ankles swell toward the end of the day or do your legs feel heavy?
______ 6. Have you ever had high blood pressure?
______ 7. Do you have varicose veins or hemorrhoids?
______ 8. Do you feel as if it is getting harder to remember or concentrate?
PART 23 _______
______ 1. Do you feel nervous and anxious much of the time?
______ 2. Do little things make you crabby or grouchy?
______ 3. Do you worry about what others think of you?
______ 4. Do your hands shake when you are excited or upset?
______ 5. Do you experience insomnia frequently?
______ 6. Are you very concerned about your appearance and/or your house?
______ 7. Do you consider yourself an "over-achiever"?
PART 24 _______
______ 1. Is it hard for you to catch your breath when exerting yourself?
______ 2. Do you smoke cigarettes? If yes, please answer with two checks.
______ 3. Are you a shallow breather?
______ 4. Do you have respiratory allergies or asthma? If yes, please answer with two checks.
______ 5. Do you have a chronic cough, sore throat, or mucous?
______ 6. Do you catch colds or sinus infections easily?
PART 25 _______
______ 1. Do you tolerate fats in your diet poorly?
______ 2. Do you frequently have gas or bloating after eating?
______ 3. Do you ever have pain on the right side under your rib cage or between your shoulder blades?
______ 4. Do you have gallbladder trouble or have you had gallbladder surgery?
______ 5. Have you ever had or do you have hepatitis?
______ 6. Do you have (females) have fibroids, hemorrhaging, hot flashes, or menstrual problems? If Yes, two checks
______ 7. Do you have symptoms of ill health that the doctors tell you they can't diagnose?
______ 8. Are you often fatigued or feel "hung-over" when you wake up in the morning?

PART 26 _______
______ 1. Do you ever experience backaches in the waist area?
______ 2. Do you ever suffer from kidney or bladder infections?
______ 3. Do you retain water?
______ 4. Do you have frequent or painful urination?
______ 5. Are your feet or ankles swollen at the end of the day?
______ 6. Do you have high blood pressure?
PART 27 _______

______ 1. Do you have repeated or chronic sinus congestion, sinus infections, or upper respiratory (lung/bronchial) problems?
______ 2. Do you have vaginal itching or discharge frequently (females) or "jock itch" (males)?
______ 3. Have you recently had or do you currently have a fungus infection or Athletes' Foot?
______ 4. Do you get frequent or recurring bladder, kidney, or prostate infections?
______ 5. Have you ever had thrush in your mouth or any unexplained skin rashes that come and go?
______ 6. Did you use antibiotics, sulpha drugs, steroids, or birth control pills previous to the occurrence of the above problems?
(Do not check #6 unless you have checked at least one other number in Part 28)
PART 28 _______

Now, if time permits, please reread all of these questions and see if you missed any of your symptoms. Careful thought to
the questions assures more accurate test results.

Rev 06/09, v4.10-4.41

 Demonstration Agreement

Congratulations on Taking One of the First Steps toward

Improving Your Health!
The Live Blood Demonstration in which you are about to participate in is
designed to demonstrate how lifestyle choices such as diet and exercise ay
affect your health. By allowing you to see what may be happening within
your own body at the cellular level, this demonstration tool serves to
motivate you to make positive lifestyle changes.

Here’s how the Demonstration works:

1. Complete a brief lifestyle questionnaire

2. Your Health Professional will review the questionnaire and then recommend lifestyle changes as needed. These
recommendations will be limited to education in sound nutritional principles, exercise, supplementation and
visualization techniques.
3. A qualified technician (Microscopist) will take a one-drop sample of blood.
4. A magnified image of your blood will be shown on a video monitor.
5. The Microscopist will show you a picture of normal blood so that you can compare it to your blood.

Terms of Agreement

Please Read Carefully:

The Live Blood Demonstration will provide me with a graphic illustration of
my live blood cell physiology. It is not a medical test, nor will any
medical diagnosis be made or implied as a result of this demonstration.
Furthermore, my lifestyle, eating habits, nutritional balance and mental
state, may affect what I see; therefore, the results may vary if I repeat
the tests over various periods of time.

I authorize the Microscopist to use a lancet to obtain the drop of

blood for the Demonstration, following OSHA-approved guidelines. I agree to
hold harmless the independent Microscopist who performs the Demonstration.
I hereby grant the independent Microscopist permission to include the
results of this demonstration in any statistical or research study. I
understand that any suggested nutrition is not intended as primary therapy
for any disease or symptom, but rather is intended to provide an added
schedule of enzymes and nutrients for the sole purpose of upgrading the
quality of nutrients delivered through the diet.

I have read, I understand and I agree to the terms above:

Signature Date

Full Name (Please Print)

Rev 06/09, v4.10-4.41