Quiz

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Do you experience symptoms as dizziness, shaking or brain fog between or following meals?
YesNo

Do you frequently miss or skips meals?
YesNo

Do you crave for sugar or chocolate?
YesNo

Are you pre-diabetic or diabetic?
YesNo

Do you regularly consume coffee or alcohol?
YesNo

If yes, how much caffeine and/or alcohol do you drink per day? coffee ____ alcohol____

Brain and emotional imbalances

Do you frequently experience anxiety?
YesNo

Do you suffer from depression?
YesNo

Do you suffer from poor memory or forgetful?
YesNo

Do you suffer from mood swing?
YesNo

Do you have difficulty getting motivated?
YesNo

Do you frequently experience feelings of agitiation, anger, fear or worry?
YesNo

Sleep Cycle imbalances

Are you experiencing problems falling asleep?
YesNo

Are you experiencing difficulty staying asleep?
YesNo

Are you not sleeping enough hours?
YesNo

Are you not able to fall into a deep sleep?
YesNo

Do you suffer from light cycle disruption or shift work issue?
YesNo

Do you frequently feel drowsy throughout the day?
YesNo

Hormonal and inflammation imbalances

Do you suffer from headaches, muscle, back or join pain?
YesNo

Do you suffer from IBS, Chrons’s disease or diverticulitis?
YesNo

Do you suffer from hives, eczema, or psoriasis?
YesNo

Do you suffer from asthma, bronchitis, seasonal allergies or hay fever?
YesNo

Do you suffer from any auto-immune condition (Thyroid, MS, Lupus, RA?)
YesNo

Do you suffer from food sensitivity or food allergy?
YesNo

Do you suffer from chronic infections or frequent illness?
YesNo

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When is the best time to contact you?

Phone number:

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