Renewed Health Company Personal Consultation www.stopyeast.com
Thank you for purchasing this personal consultation - I am looking forward to working with you.
This personal consultation tool is unique - you will not find another one out there like it anywhere.
This questionnaire will give me an excellent feel for the types and severity of symptoms you are struggling with. Based on these symptoms I will be able to come up with a detailed plan of action for you. Some questions are asked more than once, these questions are grouped into different areas which will help me to determine what may be causing the symptom and to give us the best chance of finding a solution for you. Please be patient with the repitition; the grouping makes it easier for me to see existing patterns.
You will receive an email with the results of this questionnaire within 24-48 hours of submission.
Results are confidential.
Contact Information
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First Name:
Last Name:
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Email Address:
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Gender
Male
Female
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Age
Country:
Section 1 - General Information
Do you have chronic constipation? (hard, difficult to evacuate stool, going less than 1 time per day).
Yes
No
How many bowel movements will you have in a day?
If less than 1 bowel movement per day, how many bowel movements will you have in a week?
Do you have trouble with loose stool or diarrhea?
Yes
No
Do you have any allergies to psyllium?
Yes
No
Do you have allergies to lemon?
Yes
No
Do you have any allergies to apples or cinnamon?
Yes
No
Are you sensitive or allergic to sulfa or sulfur?
Yes
No
Are you sensitive to medications?
Yes
No
Section 2 - Candida Symptom Evaluation
Indicate the level of severity of each symptom.
absent
intermittent
mild
moderate
severe
incapacitating fatigue
concentration/focus problems
short term memory
acid reflux
brown colored mucus in throat
white/blood blisters in mouth/throat/tongue
unrefreshing sleep
sore throat
white coated tongue
aversion to being touched - "crawling skin"
chronic sinusitis
frequent urination
chronic diarrhea
chronic constipation
visual blurring
eye pain
personality changes
mood swings
canker sores
sensitivity to hot/cold
alcohol intolerance
gluten intolerance
irritable bowel
painful gas/abdominal bloating
dryness of mouth/eyes
absent
intermittent
mild
moderate
severe
projectile vomiting
menstrual pain/problems
recurrent yeast infections
recurrent ear infections
acne
skin/discoloration blotching
jock itch
chronic athlete's foot
chronic toenail/fingernail fungus
allergies
sensitivity to noise/sounds
do you have sensitivity to foods and chemicals
sensitivity to odors
anemia
weight changes w/o changes in diet .
inability to lose weight
lightheadedness
feeling in a fog
fainting
low sex drive
Section 3 - Magnesium Deficiency
Indicate severity of symptom.
absent
intermittent
mild
moderate
severe
muscle twitches/cramps/spasms/tension
heart palpitations/arrythmias
leg spasms, charlie horses
restless leg syndrome
back aches, neck aches
headaches, migraines
jaw joint problems
need to sigh a lot, unable to take a deep breath
chest tightness
urinary spasms
constipation
menstrual cramps, premenstrual irritability
difficulty swallowing
sensation of a lump in throat
insomnia
light sensitivity
loud noise sensitivity
anxiety
panic attacks
hyperactivity
high blood pressure
numbness, tingling, zips, zaps and other vibratory sensations
being uptight or prone to temper
angina
hiccups
Section 4 - Toxicity
Indicate level of severity
absent
intermittent
mild
moderate
severe
skin rashes
itchiness that travels around the body
skin breakouts
dry/flaking skin
brain fog
joint or muscle pain that travels around the body
tightness in the muscles
insomnia
vivid or bad dreams
dizziness or vertigo
night sweats
fevers or chills
vaginal discharge/itching that comes and goes
other skin conditions (eczema or psoriasis flare ups)
tinnitus (ringing in the ear)
dandruff
dermatitis
Section 5 - Heavy Metals
Indicate level of severity
absent
intermittent
mild
moderate
severe
vomiting, nausea
diarrhea
stomach pain
headache
sweating
metallic taste in the mouth
there is impairment of cognitive/motor skills
numbness
burning sensation in the skin
dizziness
immune suppression
nervous system disorders
anemia
skin rashes
skin cracking
high blood pressure
memory loss/mental confusion
tremors
hyperactivity
muscle weakness/aches
autism
visual problems
kidney problems
Indicate level of severity
absent
intermittent
mild
moderate
severe
bloating
foggy memory
food cravings
mild, nagging headache
anal itching
insomnia
waking at 2 AM
bronchitis
tiny, red abrasions that itch
rash
irritable, grumpy
malabsorption
gas
allergies
abdominal cramping
anemia
coughing
fever
restlessness
Any additional comments
Form Complete - Thank you!
Thank you for completing this form. Please submit the form. This information will be analyzed in the next 24 hours and you will receive an email from us soon.
If you would like a copy of data you placed in this questionnaire, please enter your email here.
Disclaimer
Renewed Health Company is an Independent Business Owner for GHT. The statements contained in this site have not been evaluated by the Food and Drug Administration (FDA). These products are not intended to diagnose, treat, cure or prevent any disease.
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