Customized Plan

Are you presently using prescription drugs?

yes
no

If yes, how many?

Please list current medications

Do you currently use or within the last 6 months have used tabacco products?

yes
no

Do you have strong negative reactions to caffeine or caffeine containing products?

yes
no
don't know

Do you commonly experience "brain fog", fatigue, or drowsiness?

yes
no

Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?

yes
no
don't know

Do you feel ill after you consume even small amounts of alcohol?

yes
no
don't know

Do you have a personal history of

Environmental and/or chemical sensitivities
Chronic fatigue syndrome
Multiple chemical sensitivity
Fibromyalgia
Parkinson's type symptoms
Alcohol or chemical dependence
Asthma
Kidney and/or liver dysfunction

Do you have a history of significant exposure to harmful chemicals such as herbacides, insecticides, pesticides, or organic solvents?

yes
no

Do you have a adverse or allergic reaction when you comsume sulfite containing foods such as wine, dried fruit, salad bar vegetables, etc?

yes
no
don't know

Do you have an additonal info and or concerns?

Do you agree to our terms of our service agreement? See below

yes
no

Are you at least 18 years of age?

yes
no