| | YES | NO |
| 1 | Do you have difficulty falling asleep? | o | o |
| 2 | Do you have difficulty waking up in the morning? | o | o |
| 3 | Do you have a weight problem? | o | o |
| 4 | Do you usually feel tired and lethargic? | o | o |
| 5 | Do you frequently suffer from headaches and migraine attacks? | o | o |
| 6 | Do you suffer from bloating and wind in your stomach? | o | o |
| 7 | Do you suffer from clenched muscles and muscles cramps in the calves? | o | o |
| 8 | Do you have difficulty to concentrate and maintaining concentration? | o | o |
| 9 | Do you suffer from sinus or nose congestion problems? | o | o |
| 10 | Do you suffer from constipation or diarrhea? | o | o |
| 11 | Do you suffer from frequent mood swings, anxiety, bouts of depression or a sense of hopelessness? | o | o |
| 12 | Are you frequently stressed and feel irritable? | o | o |
| 13 | Does your hair feel dull and lifeless? | o | o |
| 14 | Do you have aches and pains in your joints that are constant or that keep recurring? | o | o |
| 15 | Does your skin look dull; or do you suffer from skin problems, such as acne, eczema or psoriasis? | o | o |
| 16 | Do you catch a cold or fall sick easily? | o | o |
| 17 | Do you drink alcohol heavily or regularly? | o | o |
| 18 | Do you drink more than 2 cups of coffee, tea or soft drinks daily? | o | o |
| 19 | Do you smoke, live with a smoker, or work in a smoky environment? | o | o |
| 20 | Do you work with toxic chemicals or in a toxic environment? | o | o |
| 21 | Do you have amalgam/mercury fillings in your teeth? | o | o |
| 22 | Do you have any food sensitivities or intolerance? | o | o |
| 23 | Do you crave sweets, breads and pastas? | o | o |
| 24 | Do you eat micro-waved foods frequently? | o | o |
| 25 | Do you eat out or take-aways frequently? | o | o |
| 26 | Do your foods consist of mostly meat and very little vegetables? | o | o |
| 27 | Have you done any major surgery before; or are you on any long-term medication? | o | o |
| 28 | Are your days mostly sedentary and you don't exercise? | o | o |