Contact Us Health SurveyFirst NameLast NameEmailPhone numberAgeGender Male Female I have read and agree to the Terms and Conditions and Privacy PolicyHealth InformationPlease answer these questions honestly to ensure an accurate health and wellness program that will help you solve the problems you came here to handle.Do you crave sweets, candy, bread, and pasta? Yes NoDo you crave chocolate or salty snacks? Yes NoDo you crave potato chips or food that is deep-fried? Yes NoDo you crave dairy products such as ice cream, cream cheese, sour cream, or milk? Yes NoAre you prone to feelings of depression or hopelessness? Yes NoAre you someone who often worries or gets anxious and nervous? Yes NoAre you snappy, irritated, and moody in the morning? Yes NoAre you moody or irritable around/during your menstrual cycle? (If you've gone through Menopause and don't have a menstrual cycle anymore, please still answer the question with info on when you were having your menstrual cycle) Yes NoDo you feel better when you eat fruits and berries? Yes NoDo you have to have coffee or other stimulants in order to wake up? Yes NoDo you sometimes have a feeling of tightness over your right lower-stomach area or rib cage? Yes NoDo you get constipated during your menstrual cycle? Yes NoDo you have vertical ridges on your nails and are they brittle? Yes NoDo you as a female, have facial hair? Yes NoDo you have pain or stiffness in your right shoulder/blade area? Yes NoDo you have pain in your lower-back or hip area? Yes NoDo you have evenly distributed fat on your body? Yes NoDo you have a pendulous belly (saggy and hangs over the belt)? Yes NoDo you have a hard protruding potbelly? Yes NoDo you have fat distributed around your thighs, hips and lower stomach area? Yes NoDo you have dry skin especially around your hands and elbows or other areas? Yes NoDo you have swelling around your ankles? Yes NoDo you have dandruff or flaky skin in your eyebrows? Yes NoDo you have hair loss that occurs during your menstrual cycle? Yes NoDo you have indentations made by your teeth on each side of your tongue? Yes NoDo you have difficulty getting up from a seated position due to weakening of your thigh muscles? Yes NoDo you have urine that is dark yellow in colour? Yes NoDo you have occasional hot flashes? Yes NoDo you have bald patches on the outer third of your eyebrows? Yes NoDo you get dizzy when you stand up too quickly? Yes NoDo you get hot or swollen feet? Yes NoDo you experience brain fog during your menstrual cycle? Yes NoDo you get cold at night and must sleep with socks on? Yes NoDo you experience chronic inflammation in your body? Yes NoDo you experience headaches or a heavy head in the morning? Yes NoDo you experience excessive bleeding when menstruating? Yes NoDo you experience puffiness around your eyes? Yes NoDo you get unusually out of breath while climbing stairs? Yes NoDo you have any psoriasis, eczema, brown spots, or other skin problems? Yes NoDo you have low libido? Yes NoDo you have flabby skin under your arms? Yes NoDo you experience twitching under or on top of your left eyelid? Yes NoDo you feel more awake at night and see yourself not as a morning person? Yes NoDo you gain weight one week before your menstrual period? Yes NoDo you experience hair loss or have dry hair? Yes NoDo you find yourself waking up in the middle of the night at 2am or 3am? Yes NoDo you have a white film on your tongue and/or a deep split down the centre of it? Yes NoDo you have a small upper body, disproportionate to your larger lower body? Yes NoDo you lose the curls in your hair after using a curling iron? Yes NoDo you get cramps in your calf muscles at night? Yes NoDo you get itchy skin at night? Yes NoDo you feel you retain water at certain times of the month? Yes NoDo you get very tired in the early evening as opposed to being more awake in the early morning? Yes NoDo you experience your bladder to be more active at night than during the day? Yes NoDo you find that the whites of your eyes have a yellowish colour to them? Yes NoDo you have or have you had ovarian or breast cysts? Yes NoDo you lack vitality and that get-up-and-go feeling? Yes NoDo you have bursitis, tendonitis, kidney stones, heel spurs, early cataracts or other calcium issues? Yes NoDo you experience grouchiness when you are hungry? Yes NoDo you find it or have found it difficult to lose weight after pregnancy? Yes NoDo you or have you taken part in low-calorie diets? Yes NoDo you become easily irritated and on edge, and can't handle stressful situations? Yes NoDo you experience stiffness and pain mostly in the right shoulder and right side of the neck? Yes NoDo you when on your menstrual cycle, have pain and stiffness in your one knee? Yes NoFinish Contact Form Demo (#5)First NameLast NameEmailSubject- Select -General ContactRefund/ReturnYour MessageSubmit Form
