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Evaluate Your Health

Do you ever have colds or the flu?
Do you suffer from infections (lungs, bladder, ears) or other fevers?
Do you have seasonal or other allergies?
Do you suffer from bloating, acid reflux, or indigestion after eating?
Do you suffer from constipation (less than 2 soft bowel movements a day)?
Do you take over-the-counter medications, or prescription drugs for pain?
Do you suffer from chronic pain, like arthritis?
Do you often feel sad?
Do you have negative relationships with those close to you?
Is your memory noticeably worse than 1 year ago?
Do you have a hard time focusing?
Do you wake up during the night or have sleep apnea?
Do you typically feel like you didn’t get enough sleep?
Do you have low energy and fatigue throughout the day?
Do you have body odor?
Do your fingernails easily chip, peel or break?
Do you have hemorrhoids or varicose veins?
Do you have high blood pressure or high cholesterol?
Do you suffer from dry skin, flaky skin or dandruff?
Has your eyesight gotten weaker over the past year?
Are you overweight / obese?
Do you suffer from frequent urination, urgency to urinate or do have to get up multiple times at night to urinate? (men only)
Do you suffer from menopausal symptoms? (women only)
Have you been to a medical doctor for an illness during the past year?
Have you lost any time from work due to illness during the past year?
Do you take any prescription medications or drugs?
Have you been diagnosed with any of the following health conditions?
Are you currently on the Hallelujah Diet?
Are you currently taking Barley Max?

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Full Name
Email Address
Age
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