New Leaf Health Supplement Survey - New Leaf Health Dallas

You'll see recommendations at the end of the survey based on your responses to the questions. You'll also receive a copy of the information in your email.

Name

Email

Notice my memory is declining

Never Rarely Often Frequently Always

Think or have better focus with exercise or caffeine

Never Rarely Often Frequently Always

Have cold hands, feet or the tip of your nose?

Never Rarely Often Frequently Always

Do not recover well after a workout

Never Rarely Often Frequently Always

Takes me days to feel better following a hard workout

Never Rarely Often Frequently Always

Feel bad after doing simple tasks

Never Rarely Often Frequently Always

Shaky, lightheaded, or irritable between meals (hangry)

Never Rarely Often Frequently Always

Feel energized after eating

Never Rarely Often Frequently Always

Hard to eat a large breakfast

Never Rarely Often Frequently Always

Crave sweets in the afternoon

Never Rarely Often Frequently Always

Depend on coffee or caffeinated beverages to get, or keep, you going

Never Rarely Often Frequently Always

Have afternoon headaches

Never Rarely Often Frequently Always

Gain weight under stress

Never Rarely Often Frequently Always

Have trouble losing weight

Never Rarely Often Frequently Always

Need coffee after meals

Never Rarely Often Frequently Always

Get tired after eating

Never Rarely Often Frequently Always

Sweat easily

Never Rarely Often Frequently Always

Difficult for me to digest foods

Never Rarely Often Frequently Always

Constipation or inconsistent bowel movements

Never Rarely Often Frequently Always

Tongue is coated with debris

Never Rarely Often Frequently Always

Excessive burping and/or bloating

Never Rarely Often Frequently Always

Heartburn subsides with rest

Never Rarely Often Frequently Always

Take antacids

Never Rarely Often Frequently Always

Have bad breath

Never Rarely Often Frequently Always

Brain fog when your inflamed or body aches/hurts

Never Rarely Often Frequently Always

Brain fog, unclear thoughts or concentration

Never Rarely Often Frequently Always

Get tired after a meal and cannot concentrate

Never Rarely Often Frequently Always

Tired after eating bread

Never Rarely Often Frequently Always

Feel better when avoiding grains

Never Rarely Often Frequently Always

I and/or a family member have been diagnosed with gluten sensitivity

Yes No

*Please answer yes or no to this question

Hypothyroidism, irritable bowel disease, celiac

Yes No

*Please answer yes or no to this question

Typically cold or sluggish

Never Rarely Often Frequently Always

Have cold hands and/or feet

Never Rarely Often Frequently Always

Need extra sleep to function

Never Rarely Often Frequently Always

Gain weight on low calories

Never Rarely Often Frequently Always

Losing eyebrow hair

Never Rarely Often Frequently Always

Difficult to move like you used to

Never Rarely Often Frequently Always

Takes a while to get moving

Never Rarely Often Frequently Always

Difficult to stand up

Never Rarely Often Frequently Always

Fall often

Never Rarely Often Frequently Always

Multiple joint injuries

Never Rarely Often Frequently Always

Increased food intolerance or sensitivitie

Never Rarely Often Frequently Always

Increased intolerance to smells, jewelry, shampoo, lotions, detergents, etc.

Never Rarely Often Frequently Always

Unexplained itchy skin

Never Rarely Often Frequently Always

Bitter, metallic taste in mouth

Never Rarely Often Frequently Always

Diagnosed with gout

Yes No

*Please answer yes or no to this question

Gallstones, gallbladder issues or gallbladder removed

Yes No

*Please answer yes or no to this question

Difficulty digesting fat

Never Rarely Often Frequently Always

Reddening skin especially in the palms

Never Rarely Often Frequently Always

Avoid spicy foods, chocolate, citrus, peppers, alcohol, or caffeine because it causes pain

Never Rarely Often Frequently Always

Heartburn lying down or bending forward

Never Rarely Often Frequently Always

Heartburn with spicy foods, chocolate, citrus, peppers, alcohol, or caffeine

Never Rarely Often Frequently Always

Pain on left side under rib cage

Never Rarely Often Frequently Always

Difficulty digesting fiber

Never Rarely Often Frequently Always

Undigested stool/mucus-like

Never Rarely Often Frequently Always

Swell after eating in the abdominal or other extremities

Never Rarely Often Frequently Always

Abdominal distention after eating solid foods

Never Rarely Often Frequently Always

Bouts of alternating constipation/diarrhea

Never Rarely Often Frequently Always

Diagnosed with celiac, leaky gut, or IBS

Yes No

*Please answer yes or no to this question

Diagnosed with SIBO

Yes No

*Please answer yes or no to this question

Are you concerned about your high cholesterol?

Yes No

*Please answer yes or no to this question

Sick all of the time

Yes No

*Please answer yes or no to this question

Lots of mucus

Yes No

*Please answer yes or no to this question

Do you feel toxic all the time?

Yes No

*Please answer yes or no to this question

Trouble falling asleep

Never Rarely Often Frequently Always

Trouble staying asleep

Never Rarely Often Frequently Always

Wake up feeling rested

Never Rarely Often Frequently Always

Do you suffer from allergies?

Yes No

*Please answer yes or no to this question

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