FREE Online Health Encyclopedia
GENERAL INFORMATION - #1 Start Here

Please answer all questions.

What is your gender? Male Female
What is your height? Feet Inches
What is your weight? Lbs
What is your age?
Are you a diabetic? Type I Type II No
Do you have a serious heart condition? Yes No
At this time do you have any kidney related problems? Yes No
Have you had your appendix removed? Yes No
Have you had your tonsils removed? Yes No
Have you ever or do you now have any form of cancer? Yes No
Do you consume caffeine in any form, such as coffee, cola nuts, guarana or energy products like "no-doz"? Yes No
Do you ever eat candy, cakes, pies, cookies, soft drinks or any white sugar products? Yes No
Do you ever eat meat or meat products? Yes No
Do you drink Black or Green Teas? Yes No
Do you eat red meats and other flesh foods. Yes No
Do you consume alcoholic beverages? Yes No
Do you use an excessive amount of salt or do you put salt on all your foods after they are served? Yes No
Do you often go without eating breakfast? Yes No
Do you consume soft drinks? Yes No
Do you often desire snacks? Yes No
Do you gulp your foods or chew them poorly? Yes No
Are you allergic to dairy products? Yes No
Are you allergic to wheat products? Yes No
Does whatever you eat seem to make you gain weight? Yes No
Do you eat ravenously but never seem to gain weight? Yes No
Do you often eat on the run? Yes No
Do you often eat in restaurants? Yes No
Do you eat eggs more than twice a week? Yes No
Do you often skip meals? Yes No
In your opinion, should you be eating more vegetables and fruits? Yes No
Do you avoid eating fresh and raw fruits and vegetables? Yes No
Do you find it difficult to get in the habit of taking supplements? Yes No
Are you presently on any special diets? Yes No
Do you seem to crave sweets? Yes No
Do you drink at least 4 to 8 glasses of liquid daily? Yes No
Do you drink city chlorinated waters (tap water)? Yes No
In your opinion, do you consume too much fat daily? Yes No
Do you snack before going to bed? Yes No
Do you smoke tobacco or marijuana? Yes No
Do you experience "heart burn" or do you have "acid reflux"? Yes No

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