Self Assessment Quiz 1 Name *FirstLastEmail *Phone Number *Date Of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Health InformationSelect your health goals:Digestive balanceWeight lossWeight gainIncreased energyIncreased focusHormonal balanceBlood sugar regulationBlood pressure balanceReduction in body inflammationIncreased nutritional knowledgeDetail your current daily eating habits for BREAKFAST.Detail your current daily eating habits for LUNCH.Detail your current daily eating habits for DINNER.Detail your current daily eating habits for SNACKS.Detail your current daily eating habits for LIQUIDS consumed.Eating HabitsRed MeatDo not consumeInfrequent consumption (few times a month)Frequent consumption (few times a week)Daily consumptionPork MeatDo not consumeInfrequent consumption (few times a month)Frequent consumption (few times a week)Daily consumptionDairy ProductsDo not consumeInfrequent consumption (few times a month)Frequent consumption (few times a week)Daily consumptionWhite Flour ProductsDo not consumeInfrequent consumption (few times a month)Frequent consumption (few times a week)Daily consumptionProcessed Sugar ProductsDo not consumeInfrequent consumption (few times a month)Frequent consumption (few times a week)Daily consumptionWine & AlcoholDo not consumeInfrequent consumption (few times a month)Frequent consumption (few times a week)Daily consumptionHealth IssuesDiabetesThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyNote: If you have Diabetes Type I you cannot do ionic detox foot baths as a detox therapy, because it may pull insulin injections from your body.Pregnancy ComplicationsThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyNote: If you are pregnant, you cannot do ionic detox foot baths as a detox therapy, because it may pull from the fetus. Food IntolerancesThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyNote: If you are pregnant, you cannot do ionic detox foot baths as a detox therapy, because it may pull from the fetus. List All Food Intolerances:High CholesterolThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyHigh Blood PressureThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyBlood Clotting IssuesThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyOverweight/ObesityThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyFibrosisThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyAutoimmune DiseaseThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyList Autoimmune Disease/s:ArthritisThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyRecent Injury/SurgeryThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyList Injury/Surgery:Chronic Pain/FibromyalgiaThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyOsteoporosis/Bone IssuesThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyAnemiaThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyCancerThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyRadiation ExposureThis Applies To Only MeThis Applies To Only My FamilyThis Applies To Both Me and My FamilyNote: X-rays, gamma rays, and other forms of ionizing radiation are used to diagnose and treat some medical conditions. This can be in the form of radiation that penetrates from outside the body, or radioactive particles that are swallowed or inserted into the body.Other/s Not Listed:Select Medications That Apply To You.AntacidsLaxativesUlcer medAntibioticsBlood thinnerHeart medicationBlood-pressure medCortisoneAnti-inflammatory medOral contraceptiveHormone medRelaxant/sleeping medThyroid medAnti-depressantOther med not listedOther Medications Not ListedSelect any symptoms you may be experiencing or recently experienced within the past few months.Bloating/gas/indigestionConstipationDiarrheaOvereatingSweets/sugar cravingsTiredness/fatiguePoor circulationFailing visionJoint pain/grinding/swellingEasy bruisingSlow recovery after sicknessMuscle crampsLight-headedness/headachesIntense migraines/sinus pressureUrinary tract pain/regular UTIsYellow discoloration in the eyesAge spotsLack of concentration/brain fogIrritability/anxietyHigh stressBack pain near the kidneysHeavy menstrual bleedingMonthly crampsFrequent colds/flu-like infectionsNameSubmit