Adult Nutrient FormPlease set aside 10-15 minutes to fill out the form below.Some fields are duplicated, please duplicate your answer.Note: this page DOES NOT autosave, please submit the form before exiting the tab. Name * First Name Last Name Email * Rate the following symptoms depending on the severity experienced. Please leave blank if a symptom does not apply. Select 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or occurring often. Nutrients 1. Excess fluid retention 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nausea or dizziness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Poor coordination 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) General, overall weakness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Anemia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cataracts 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Catch cold, flu and/or infections easily 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cuticles tear easily 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hair dull, dry, sparse, loose and falling 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 2. Rough, dry, flaky or scaly skin 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry brittle hair 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Eczema 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Psoriasis 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irregular menstrual period 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Minerals 3. Osteoporosis 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bones break easily 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irregular heartbeat 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Brittle nails 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscle cramps 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Crowded teeth 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscular weakness & fatigue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Insomnia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 4. High cholesterol 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Intolerance to alcohol 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Diabetic or hypoglycemia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Overweight 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Sugar cravings 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Chronic dieter 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Kidney disease 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 5. Fatigue; extreme lack of energy 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry hair 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Thyroid problem 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Overweight 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Constipation 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cold hands and feet; always 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Brittle nails 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 6. Lack of energy 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dizziness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Craving for ice 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pale lower eyelid 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Tachycardia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Spoon shaped nails 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 7. Muscle spasms 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Gallstones 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cravings for chocolate 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irregular heartbeat 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Excessive body odor 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 8. Joint paint 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bursitis, tendonitis 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Prone to injuries 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Weak knees 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Creaking or clicking joints 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscle weakness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 9. High blood pressure 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Swelling of ankles 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Always thirsty 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irregular heartbeat 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 10. Dry hair 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Thin hair 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Weak immunity; frequent infections 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dandruff 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cataracts 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 11. White spots on fingernails 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Acne 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Make poor sperm production 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Frequent infection 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Poor dream recall 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cuts/wounds heal slowly 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of sense of smell or taste 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Thinning hair 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Red stretch marks 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Vitamins 12. Hard little bumps around elbows 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry or rough skin 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dry hair; acne 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Poor night vision; night blindness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Susceptibility to respiratory infections 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Slow light to dark adaption 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Eyes unable to produce tears; dry 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Weak tooth enamel 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Dandruff 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 13. Fatigue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Apathy, depression 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of knee jerk response 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irregular heartbeat 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) G.I. tract disorders 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 14. Dry skin around nose and lip 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cracks/sores in corner of mouth 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bloodshot or itchy eyes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Abnormal hair loss 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Painful purplish/red tongue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 15. Sore tongue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Fatigue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of appetite 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Skin disorders 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Swelling of mouth 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Smooth tongue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Mental confusion 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of sense of humour 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Cancer sores in mouth 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 16. Anemia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irritability or nervousness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Insomnia, poor dream recall 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Sore thumbs, kidney stones 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Female: acne worse during menstruation 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Female: morning sickness during pregnancy 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 17. Fatigue & weakness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Lightheadedness or dizziness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Heart palpitations 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Shortness of breath; chest pain 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Sore, red, glazed looking tongue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irritability; inability to concentrate 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Ringing in ears (tinnitus) 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nausea and diarrhea 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Memory loss; forgetfulness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 18. Skin disorders 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Smooth and pale tongue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Loss of appetite 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pale fingernails 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irregular heartbeat 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Mild anemia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Hairloss 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 19. High blood pressure 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) High blood cholesterol 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Eczema 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bleeding ulcer 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Disoriented, memory loss 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Difficulty losing weight 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 20. Paleness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Sore red tongue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Bleeding gums 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Diarrhea 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Insomnia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irritability 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Fatigue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 21. Constipation 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) General gastrointestinal disorders 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Premature grey hair 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Depression and irritability 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Fatigue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Headache 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 22. Abdominal pain 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Anorexia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nausea 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Burning feet 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Depression & irritability 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Headache 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nervousness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Purplish red tongue 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 23. Bleeding gums 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Urinary tract infections 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Abnormal nose bleeds 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Slow healing of wounds 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) General weakness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Shortness of breath 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Skin bruises easily 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Ruptured blood vessels in eyes 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Excessive hair loss 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Aching bones and joints 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 24. Muscle weakness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Pain in ribs, spine, legs 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Malformation of bones 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Osteoporosis 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscle cramps 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Rickets, insomnia 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Nearsightedness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) 25. Heart disease 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Premature aging 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Weakness 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Irritability 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Diarrhea 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Poor skin condition 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Brittle hair 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Muscle wasting 1 (Mild or rarely occurring) 2 (Moderate or regularly occurring) 3 (Severe or often occurring) Thank you for your form submission. BACK TO ALL FORMS
