Individualized Nutritional Assessment Program

Please answer the following questions to the best of your ability. 
All answers are held with the strictest of confidentiality to safe guard your privacy.
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Last Name:

First Name:

Phone (Day)

Phone (Evening)

E-Mail: 

Zip Code:

Height:

Weight:

Date of Birth:

Hair color as a child:         Eye color:        Do you have porcelain skin

How did you hear about us

Promotional Code 

Please answer each of the question as best you can with one of the selections listed below.
Use the space at the end of the test, if you need to explain any of your answers.
      Never - (never experienced it) Before - (experienced it before but not currently)
      Presently - (currently experiencing it but not before) Continuously - (experienced it throughout your life)
   
Allergic to pollen, ragweed or grass ?
Allergic to any foods ?
Allergic to dust or molds ?
Allergic to cats or other animals (Animal dander)  ?
Dedicated runner/jogger ?
Feeling faint or having black outs ?
Constant feeling of hunger ?
Chronic fatigue or tiredness ?
Shakiness or trembling after missing meals ?
Drop in energy around 3:00 PM ?
When experiencing an energy drop do you crave or eat sugar foods? Candy, soda, caffeine ?
White spots on fingernails ?
Attention Deficit Disorder or ADH ?
Ringing in the ears ?
Have you ever experienced painful PMS symptoms during menstruation ? (cramps, bloating, mode swings, headaches) ?
Adult males only - Recurrent impotence ?
Experience hyperactivity ?
Experience hyperactivity or irritability after consuming chocolates ?
Affinity for spicy foods (Crave the taste of flavorful foods) ?
Is your appetite low in the morning ?
Stretch marks on your skin ?
Skin sensitive to clothing, labels, fibers, etc. ?
Skin sensitivity to metals and jewelry ?
Allergic to common household chemicals ? (soaps, bleach, paint, etc.)
Do you have digestive problems ?
Do you have a tendency toward abdominal or stomach pain, hyperacidity or indigestion ?
Do you have excessive or recurring intestinal gas ?
Does your tongue have a white coating on it in the morning ?
Do you have small bumps on your skin located on the back of your upper arms ?
Are you a night person ?
Do you only gain weight around your mid section ?
Are you unable to lose weight around your midsection ?
Do you experience anxiety or panic attacks ?
Do you have trouble GETTING asleep?

You are half way finished with the test !

How often do you experience the following: Never, Sometimes, Frequently

Headaches

Being a perfectionist

Use of Anti-histamines

Craving for sweets

I complete new projects that I start

Feeling drowsy after meals

I procrastinate starting a new project

Recalling your dreams

Feeling blue

If you diet, do they work for you ?

Please indicate if a blood relative has experienced any of the following:
Cancer Mother Father Brother/Sister Aunt/Uncle Grandparent
Heart Disease Mother Father Brother/Sister Aunt/Uncle Grandparent

Please rate the following traits: Low, Moderate low, Average, Moderate high, High:

Amount of body hair

Adult only - sex drive

Sensitivity to food

Artistic tendencies (fine arts/performing arts i.e. dance, sing, paint, sculpt)

Amount of saliva and tears

Drive for perfection (work - school)

Obsessive compulsive tendency

Level of self motivation (school - work)

Addictive tendency (smoking, drugs, alcohol, work, gambling, shopping)

Emotional Irritability

Sunburn tendency

Tendency for infectious disease (colds, flu, etc.)

Tendency for strong anger or tantrums

Concentration wanders

Tendency for diarrhea

Tendency for constipation

Weight as a child

Tendency to gain weight

Senior moments - short term memory lapse

Have you ever experienced or been diagnosed with any of the following?
Anorexia or Bulimia Diabetes Acne Dry Skin
Serious depression Hypoglycemia Eczema Candida
Behavior Disorders Alcoholism Psoriasis Heart Disease
Thyroid Problems Alcoholic drinks/day Drug Addictions Schizophrenia
Cancer Smoking - packs/day Liver Disease Kidney Problems

Only six questions left!

Use this space for notes and to clarify any of your test answers.

What is your important health goal? {lose weight, more energy, mental clarity, etc.} 


List any medical conditions you have:


List any supplements, medications or prescriptions that you are currently taking:


List any foods that you have an allergy to, include any sub acute reactions and intolerances:


Exercise: I exercise times per week for a total of hours per week.
The type of exercise I regularly do is:


 

Order Information
The Signature Supplements Program is designed to provide you with the essential nutrients to assist your body  to create healthy, youthful cells every day. (Over 6 billion daily!) Most clients notice beneficial effects or improvement after taking the supplements for 6 months. This is not an over night results program. It takes time to reverse the aging, toxicity and imbalances that we have had for a lifetime. We recommend you take your supplements daily and then Retest after six months.
 

The Free Test Results - emailed to me within 72 hours - a two page overview of my test results.

Email to me my Test Results and my 12+ Page Individualized Nutritional Profile for $29.95 within 72 hours which contains:
      - Individualized list of supplements to increase and avoid,
      - Individualized list of foods to eat and avoid, 
      - My bio matched weight loss program,
      - Test results from questionnaire,
      - My individualized exercise program and protein to carbohydrate ratio. 

Order all - Email my Test Results and Individualized Nutritional Profile and ship Individualized Signature Supplements
     containing my vitamin, mineral and amino acid formula (60 to 80 day supply based on my weight*), 
     The price of my supplement is based on the cost of the ingredients in my formula, prices range
     from $119.43 to $129.57 plus $7.00 S&H for a 240 capsule supply (International shipping add $16.00) My individualized nutritional 
     profile is free. (Save $29.95.) The program is auto-shipped and billed to my credit card to maintain an ongoing supply 
     of nutrients. I may cancel at any time. My Signature Supplements™ are sold with a 60 day 100% money back guarantee.

     *The Signature Supplements™ are formulated to match your biochemistry and weight. Based on weight:
     Follow Signature Supplements™ label for the amount of capsules you need to take.

Billing Information: as listed on credit card

Last Name:

First Name:

Address:

City:

State:

  Zip:


Shipping Information: Name and Address if other than above

Last Name:

First Name:

Address:

City:

State:

  Zip:

Payment Type: *Credit Card  *Exp Date
*Credit Card 3 digit verification number located on the reverse side of your credit card

* O.K. to charge to my Credit Card
If you are concerned about ordering with your credit card on a secure web site  
Please fill out the entire form excluding the credit card information
Then call us at 301 874-1797 and we will gladly take your order over the phone.


By typing "yes" in the box below signifies that the information above is accurate and complete to the best of your knowledge