Name?

Phone?

What is your age?

Where do you live?

Are you male or female?

How many people live with you?

How did you find my website?

What have you been diagnosed with?

Do you like to cook?

Have you eliminated specific foods from your diet?

For how long?

Do you suffer from weakness, muscle or joint pain, swelling, tingling or numbness?

Do you have poor circulation?

Do you itch often?

Do you suffer from headaches, bronchitis, asthma or allergies?

Do you feel worse when exposed to mold, dust, chemicals or pollutants?

Do you suffer from rashes, athlete’s foot, jock itch or yeast infections?

Do you feel worse when deprived of sugars and carbohydrates such as potatoes and bread?

What foods are you sensitive to?

What are your symptoms/reactions?

Do you suffer from indigestion or acid reflux?

Does your esophagus make “gurgling” sounds?

Do you cough after eating or drinking?

Do you suffer from indigestion, gas, bloating, diarrhea or constipation?

How many bowel movements do you have daily?

Are they formed?

Do they pass easily?

Which color: Yellow, grey, brown or black?

Do you have abdominal soreness?

Do you have heart pains or palpitations?

Do you have gynecological disorders: PMS; irregular, ppainful or no menstrual cycles; hot flashes?

For what conditions do you take prescription drugs?

What supplements/herbs/medications do you take?

Do you make the SCD 24-hr lactose-free yogurt?

How often do you wake during the night?

Do you have leg/foot/toe cramps or restless legs at night?

On a scale of 1-10, how do you feel when you wake in the mornings (1 being great & 10 being awful)?

Do you feel alert or foggy-brained during the day?

Do you have unusual bouts of depression, anger or irritability?

Are you overweight or underweight?

Have you been diagnosed with an autoimmune disease?

Do your parents or children suffer with digestive/intestinal/bowel problems?

Do you feel “hopeful” or “hopeless” about your health and/or disease?

Do you need help quickly with anything?

Would you like to be on my email list for future announcements?

THANK YOU!

Copy and paste this Questionaire into an email, answer the questions and email it to kstence@marykay.com if you would like recommendations.