FREE Metabolic Screening Questionnaire

Rate each of the listed symptoms based on your typical health profile.

This FREE health questionnaire will help isolate vitamin deficiencies and provide nutrition information on natural vitamin and mineral supplements especially for you. Just fill it out, and your FREE personalized health program will be sent to you by email.

Privacy: 

The information you provide is treated in the strictest confidence. Your communication is absolutely private and no portion of your personal information will ever be shared.  The results will be emailed to the email address you provide below. 

Instructions: 

First, enter your name, age, sex and contact information.

Then in the boxes below, enter a number according to the point scale below:

0 - Never or almost never have the symptom

1 - Occasionally have it, effect is not severe

2 - Occasionally have it, effect is severe

3 - Frequently have it, effect is not severe

4 - Frequently have it, effect is severe

Do not leave any box BLANK.

Name:
Birthdate:
Sex: Male          Female
Email:
(Required for your response)
Phone
Address: 
City:
State/Province:   
Zip/Postal Code:
Country  

Please enter either a 0, 1,2, 3 or 4, as indicated in the above instructions:

Head

   Headaches
   Faintness
   "Dizziness
   Insomnia

Eyes

   Watery or itchy eyes
   Swollen, reddened or sticky eyelids
   "Bags or dark circles under eyes
   Blurred or tunnel vision
(does not include near or far sightedness)

Ears

   Itchy ears
   Earaches, ear infections
   Drainage from ear
   Ringing in ears, hearing loss

Nose

   Stuffy nose
   Sinus problems
   Hay fever
   Sneezing attacks
   Excessive mucus formation

Mouth/Throat

   Chronic coughing
   Gagging, frequent need to clear throat
   Sore throat, hoarseness, loss of voice
   Swollen or discolored tongue, gums, lips
   Canker sores

Skin

   Acne
   Hives, rashes, dry skin
   Hair loss
   Flushing, hot flashes
   Excessive sweating

Heart

   Irregular or skipped heartbeat
   Rapid or pounding heartbeat
   Chest pain

Lungs

   Chest congestion
   Asthma, bronchitis
   Shortness of breath
   Difficulty speaking

Digestive Tract

   Nausea, vomiting
   Diarrhea
   Constipation
   Bloated feeling
   Belching, passing gas
   Heartburn
   Intestinal/ stomach pain

Joints/Muscle

   Pain or aches in joint
   Arthritis
   Stiffness or limitation of movement
   Pain or aches in muscles
   Feeling of weakness or tiredness

Weight

   Binge eating / drinking
   Craving certain foods
   Excessive weight
   Compulsive eating
   Water retention
   Underweight

Energy/Activity

   Fatigue/ sluggishness
   Apathy, lethargy
   Hyperactivity
   Restlessness

Mind

   Poor memory
   Confusion, poor comprehension
   Poor concentration
   Difficulty in making decisions
   Stuttering or stammering
   Slurred speech
   Learning disabilities

Emotions

   Mood swings
   Anxiety, fear, nervousness
   Anger, irritability, aggressiveness
   Depression

Other

   Frequent illness
   Frequent or urgent urination
   General itch or discharge