TestRepeat

Signature Supplements™ 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. This is a secure site with 128-bit SSL encryption to protect your information. ANSWER ALL QUESTIONS ONLY FOR THE TIME YOU HAVE BEEN TAKING THE SIGNATURE SUPPLEMENTS

Last Name:		First Name:
E-Mail:		Zip Code:

Weight:

Date of Birth:

Answer all questions based on your observed symptoms since you started taking the Signature Supplements 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 since taking the Signature Supplements have 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 projects	Recalling your dreams
	Feeling blue	If you diet, do they work for you ?

Please rate the following traits based on your experiences since taking the Signature Supplements: 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

Only six questions left!

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

What changes you have notice since taking the Signature Supplements?

List any changes to any medical conditions since taking Signature Supplements :

List any changes in your medications since taking Signature Supplements:

List any abnormal reactions since taking the Signature Supplements:

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

Phone (day):

Phone (evening):

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