Health Questionnaire

Do you feel run down? Tired and fatigued? This questionnaire was designed to see if it is possiable if Vitamin and Mineral deficiency is the cause! Originally written by Dr. Louie Yu.

Do you have too much stress? Hard to sleep at night? This questionnaire was designed to see if it is possiable if Vitamin and Mineral deficiency is the cause! Originally written by Dr. Louie Yu.

What is your age?
Under 18 Years Old
18 to 24 Years Old
25 to 30 Years Old
31 to 40 Years Old
41 to 50 Years Old
51 to 60 Years Old
Over 60 Years Old
What is your gender?
Male
Female
1. On average, do you eat fewer than five fruit and vegetable servings per day?
Yes
No
2. Do you often experience a scaly, flaky, seborrheic condition at the outer nose margins above the lips?
Yes
No
3. Do you have soft nails or nails that chips, crack, or peel easily, and/or are brittle or contain ridges (rather than being smooth)?
Yes
No
4. Are there white spots under your fingernails?
Yes
No
5. Have you noticed small red spots under your skin?
Yes
No
6. Has your skin been damaged by sunlight and/or do you use a tanning bed more than once per month?
Yes
No
7. On average, do you consume more than three alcoholic beverages per week?
Yes
No
8. On average, do you drink more than two cups of coffee or caffeinated tea (of any kind) per day?
Yes
No
9. Are you a smoker?
Yes
No
10. On a scale of one to five, is the daily stress level in your life three or greater , if one is a low level of stress and five is the highest level?
Yes
No
11. Do you often experience cracks at the margins of your lips?
Yes
No
12. Do you often experience a sore or burning tongue?
Yes
No
13. Have you experienced a reduced ability to taste food?
Yes
No
14. Do youy gums bleed easily?
Yes
No
15. Do you bruise easily?
Yes
No
16. Are you a slow healer from bruises and cuts?
Yes
No
17. Do you feel chronically tired?
Yes
No
18. Do you have irregular eatin patterns?
Yes
No
19. Are you on a weight-loss or calorie-restricted diet (less than 2000-2500 calories per day)?
Yes
No
20. Do you feel run down and/or are you experiencing a weakenede state of immunity?
Yes
No
21. Does your hair fall out easily, and/or is it dry and brittle, and/or does it lack optimal lustre and sheen?
Yes
No

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