General InformationLast Name *First Name *Age *Date Of Birth *Sex *MaleFemaleAddress *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryHeight *Weight *Hair Colour *Occupation Phone *Email * HealthWhat are your main health concerns or conditions? Please list any medications or food supplements you are currently taking (please include botox/dyport if using now or in the past): Please list any recent medical tests results you have, such as blood tests: Please list illnesses in your family such as heart disease, cancer, TB, diabetes or arthritis: About how many hours of sleep do you get per day? How often and what kind of exercise do you do? DietWhat are typical breakfasts for you? (Food and Beverages)Mid-morning Snacks (Food and Beverages) What are typical lunches for you? (Food and Beverages)Mid-afternoon Snacks (Food and Beverages) What are typical dinners for you? (Food and Beverages)Evening Snacks (Food and Beverages) Symptoms ChecklistMark an X in the box underneath symptoms you experience, if symptoms are severe or especially important to you mark XX Acne Addiction (General) Addiction, Alcohol Addiction, Chocolate Addiction, Cigarette Addiction, Drug Aggression AIDS Alcoholism Allergies Alopecia ALS Alzheimer's Disease Anemia Anger Anger Angina Anorexia Anxiety Arteriosclerosis Arthritis Arthritis, Osteo Arthritis, Psoriatic Arthritis, Rheumatoid Asthma Atherosclerosis Autism Attention Deficit Disorder Back Problems Bad Temper (Temper Problems) Bed Wetting Behavior Problems Bladder Infections Blood Clots Blurred Vision Boils Breast Lump (Lump In Breast) Breast Tumor Bronchitis Brown Spots On Skin Bruising Buerger's Disease Burning Feet Bursitis Calculus, Biliary Calculus, Renal Cancer Candida Albicans Canker Sores Cardiac Arrythmias Cardiovascular Disease Carpal Tunnel Cataracts Celiac Disease Cerebral Palsy Chronic Fatigue Syndrome Cigarette Smoker Cirrhosis Of The Liver Collitis Collagen Disease Compulsive Behaviour Constipation Coronary Occlusion Craving Sweets Crohn's Disease Cushing's Disease Cystic Fibrosis Dandruff Defensiveness Depression Dermatitis (Skin Problems) Diabetes Diarrhea Difficulty Taking Supplements Diminished Growth Rate Diverticulosis Dizziness Drug Addiction Dry Mouth Dyslexia Ear Infection Eczema Edema, Water Retention Emotional Problems or Emotional Instability Emphesyma Endometriosis Epilepsy Epstein-Barr Syndrome Euphoric (Loss of Awarness) Exhaustion Fatigue Fever Fibromyalgia Fractures Frequent Urination Fungus Under Nails Gall Bladder Problems Gall Stones Gas (Indigestion) Gastric Ulcer Gastritis General Good Health Glaucoma Growth Rate (Diminished) Growth Rate (Stunted) Gout Hair Loss Hair Growth, Poor Headaches Headaches, Migraine Hearing Problems Hemochromatosis Hemerrhoids Hemosiderosis Hepatitis Herpes High Blood Pressure (Hypertension) Hives Hiatal Hernia HIV Positive Hodgkin's Disease Hot Flashes Hostility Hyperactivity Hypercholesterolemia (High Cholesterol) Hyperkinesis Hyperlipidemia Hypertension (High Blood Presure) Hyperthyroidism (Over Active Thyroid) Hypoadrenocorticism Hypoglycemia Hypothyroidism (Under Active Thyroid) Immune Deficiency Impotence (Men Only) Indigestion (Bloating, Gas) Infections Infections, Ear Infection, Respiratory Infections, Yeast Infertitlity Inflammation Insomnia Irritable Bowel Syndrome Irritability Iritis Joint Pain Keloid Scars Kidney Problems Kidney Stones Lactating Mother Learning Disabilities Leukemia Loss of Appetite Loss of Balance Loss of Concentration Loss of Self Esteem Lump in Breast Lupus Erythematosus Memory Loss Meniere's Syndrome Menstrual Problems Amenorrhea, Cessation of Period Dysmenorrhea (Painful Periods) Mental Confusion Mental Problems Mental Retardation Mind Racing Migraine Headaches Mononucleosis (Mono) Mood Swings Mouth Dry Multiple Chemical Sensitivity Multiple Scelrosis Muscle Cramps Muscle Tone Poor Muscle Weakness Muscular Dystrophy Myositis Myositis Ossificans Nail Growth (Poor) Nail Ridges Nails are Soft Nausea Negative Feelings Nervousness Nervous System Dysfunction Neuralgia Neuritis Nightmares Obesity Osteoporosis Ovarian Pain Pain Between Shoulder Blades Panic Attacks Paranoia Parkinson's Disease Perceptual Motor Problems Periodontal Disease Phlebitis Phobias Pigmentation Problems/Skin PMS Poor Attitude, Outlook Poor Circulation Poor Concentration Poor Digestion, Indegestion Poor Memory Poor Muscle Tone Pregnant Protein Catabolism Pre Menstrual Tension, PMS Prostate Problems Psoriasis Psychological Problems Raynaud's Disease Retinitis Rheumatism Ringing in ears Schizophrenia Sclerodermia Scoliosis Sciatic Nerve Problem Sexual Desire, Decreased Sinus Problems Sinusitis Skin Problems, Dermatitis Skin, Brown Spots Skin, Dry Skin, Flaky Skin, Itchy Skin Rash Spider Veins Stress Stomach Problems Suicidal Tendencies Tachycardia Taking Birth Control Pills Temper Problems (Bad Temper) Tendinitis Thrombophlebitis Tinnitus, Ringing in the ears Tourettes Syndrome Tumors Tumors, Benign Tumors, Fatty Tumors, Fibroid Ulcer, Gastric Ulcer, Skin Uremia Urination Problems (Frequent Urination) Urinary Infection Varicose Veins Vegetarian Vitiligo Volatility Water Rentention Weight Gain Weight Loss White Spots On Nails Worrying Wound Healing (Poorly) Yeast Infections Other symptoms that are bothering you or additional comments VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
