Print out the questionnaire below, answer all questions and then return with your sample mailing

Request for Hair Nutrient Evaluation

Print your full name__________________________________________________________

Date of Birth ________________Sex ____________Weight ____________Hgt. _________

Hair test sample source (Circle one)

Head             Nape of Neck            Pubic            Arms            Legs            Underarms            Chest

Natural Hair Color: (Circle one)     Black     Blonde     Brown     Brunette     Grey     Red

Past 60 days have you used:         Perm         Dye         Bleach        Hi lite        Color

Shampoo used_______________________________________ Conditioner used_________________________________

Do you currently consume aspartame or Suclarose?      Yes        No 

Did you ever consume chemical sweeteners?               Yes        No 

How long have you been using or how long did you formerly consume chemical sweeteners?______________________

Did your poor health symptoms begin after using artificial sweeteners?       Yes        No

Did you before or do you currently use Equal (the blue packet)?                Yes        No

Please list below diet products (low carb, sugar-free) that you did or currently use. ____________________________________________________________________________________________

____________________________________________________________________________________________

Please list below any nutritional supplements and/or vitamins that you did or currently use.

_____________________________________________________________________________________________

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Circle one/Explain

Do you have allergies? If so, please explain:    Seasonal         Molds         Food       In house airborne    Pet Hair

______________________________________________________________________________________________

______________________________________________________________________________________________

Stomach problems (circle as required)?    Indigestion     Constipation     Diarrhea    Acid Reflux     Heartburn    Nausea

Our you currently using any prescription or non prescription drugs for your stomach problems?        Yes        No

Do you have diabetes (circle)?    Type I     Type II     No

How many hours do you sleep per night on average?______________

How do you feel when you wake up?    Rested     Tired     Depressed     Sore

Please circle all that apply:

Do you currently take medications? Please list medications you use/used regularly:    Yes     No

___________________________________________________________________________________________

Have you ever had surgery?     Yes     No    If so, please explain your surgery below:

___________________________________________________________________________________________

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Have you been exposed to environmental/occupational/industrial / or chemical hazards (military bases,

telecommunications, mining, painting, work place solvents, welding, pesticides) etc. ?        Yes    No

Are you concerned about your weight?    Yes    No

Do you ever yo-yo diet?        Yes    No

Did you use tobacco (cigarettes) In the past?     Yes     No     How long if applicable?___________   

Do you smoke currently?     Yes    No    How much?__________    Are you exposed to second hand smoke?     Yes    No

Do you or have you chewed tobacco or snuff?    Yes    No      About how much_____________________________

Please circle all that apply: