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Body System Questionaire

Here is a simple way for you to find out what body systems may need additional nutritional support.  Check the symptoms you are having and send it off to me.  I will email you (within 24 hours) your results and possible recommendations for restoring vibrant health!  You are under no obligation.  The test is free for all!

Please check any symptoms you have had in the past three months.

* Required fields
Name *
E-mail Address *
City & State *
Your Age *
Are you Male or Female? *
Abdominal Pain or Discomfort
Absent-mindedness or forgetfulness
Acid indigestion or heartburn
Anxiety, nervousness or tension
Asthma
Bad breath or body odor
Brittle fingernails
Burning or painful urination
Cold hands and feet
Colitis or other bowel irritations (IBS, etc.)
Congested air passages
Constipation or dry stools
Cravings for fat or high fat diet
Cravings for sugar
Dark circles or puffiness under the eyes
Difficulty getting to sleep
Dizziness or light headedness
Dry skin
Excess mucus production
Family history of heart disease
Fatigue in the afternoons
General fatigue or low energy levels
Food allergies
Food sits heavy on stomach after eating
Frequent backache
Frequent cough
Frequent infections
Frequent urinary tract infection
General weakness or chronic illness
Hayfever
Heart problems
High Blood Pressure
High cholesterol
Impotency (males only)
Infertility
Intestinal gas or bloating
Itchy nose and ears
Joint pain, arthritis or gout
Leg cramps or pains
Less than one bowel elimination per day
Loose stool or diarrhea
Loss of appetite or poor appetite
Loss of sexual desire
Menopause problems (females only)
Menstrual problems (females only)
Mental/emotional distress
Migraine headaches
Muddled thinking or confusion
Osteoporosis
Pale complexion and/or anemia
Prostate problems (males only)
Restless dreams or nightmares
Scant or excessive urination
Sinus congestion
Sinus headaches
Skin problems (acne, rashes, etc.)
Stiff, aching or painful muscles
Swollen lymph glands
Ulcers
Underweight or unable to gain weight
Waking up to urinate
Varicose veins
Waking up frequently during the night
Water retention or edema
Weak legs, knees or ankles
Wheezing or shortness of breath
Wounds that won't heal on extremities
Anything else not mentioned that is causing problems?
If Female, are you: *
What prescription medications do you take? *
What nutritional supplements do you take? *

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Thank You for participating.

Donna Anthony, CNC