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					Hair Analysis Testing
With Nutritionally Yours
               Hair SOLUTIONS
            HEALTH Analysis is a great way to understand what your body needs in order to feel healthy
                  and work optimally.

                                                             QUESTIONAIRE
       Questionnaire is only required for Clients who are requesting a Complete Package or Platinum Package

                                 PLEASE MARK THE BOX’S THAT APPLY TO YOUR HEALTH


1.   □ I suffer from symptoms of attention deficit or brain fog.   26. □   I wake up during the night to eat.

2.   □ I suffer from symptoms of attention deficit hyperactivity   27. □  I feel hungry all the time and my appetite is never satisfied
     syndrome.                                                         when I eat.
3.  □ (children) I have trouble focusing in school.                28. □ (Women) I have hot flashes and night sweats.
4. □ I suffer from too many cold and sinus problems.               29. □ (Women) I have PMS that negatively affects my life and

5. □ I have asthma or trouble breathing at times.
                                                                       mood.
                                                                   30. □   (Women) I have vaginal yeast discharge
6. □ My stools are hard and I am constipated.
                                                                   31. □   I drink diet soda regularly.
7. □ My stools are loose and I get diarrhea too often.
                                                                   32. □   I am on a low-carb diet.
8. □ I have gas, bloating and/or heartburn.
                                                                   33. □   I have autism
9. □ I have irritable bowel syndrome.
                                                                   34. □   I feel toxic.
10. □ I have high blood pressure.
                                                                   35. □   I eat a lot of dairy
11. □ I have high cholesterol.
                                                                   36. □   I eat wheat often
12. □ My energy is low.
                                                                   37. □ I am on medication(s)
13. □ I have bad anxiety and stress.
                                                                   38. List the medications below
14. □ I suffer from depression.                                        ____________________________________
15. □ I am overweight.                                                 ____________________________________
                                                                       ____________________________________
16. □ I am underweight.                                                ____________________________________
17. □ I suffer from headaches or migraines.                        39. Additional Information
18. □ I suffer from acne, rashes, eczema or psoriasis.                 ____________________________________
                                                                       ____________________________________
19. □ My hair is dry and breaks easily.                                ____________________________________
20. □ I have been on over 10 rounds of antibiotics in my life.         ____________________________________
21. □ I suffer from arthritis and or chronic pain.                     ____________________________________
                                                                       ____________________________________
22. □ I have an auto-immune illness.                                   ____________________________________
23. □ I have Fibromyalgia.                                             ____________________________________
24. □ My body is very weak.                                            ____________________________________
                                                                       ____________________________________
25. □ I cannot get a good nights sleep.                                ____________________________________
                                                                       ____________________________________

				
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posted:10/27/2011
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