Skip to content
Call or Text Us Today! 919-675-2384
|
thehealingfoodplan@proton.me
Search for:
Home
Articles
Services
Free Resources
Morning Routine Reset
About Us
Contact
Search for:
Intake Survey
mark
2023-02-25T21:00:20+00:00
Intake Survey
1.Who referred you?
2.List your health concerns.
3.Overall, would you be willing to make habit and/ lifestyle modifications to change your health outcome?
I am open to making 3-4 new habit changes a month with email/call support to help guide me.
I am open to making 2-3 new habit changes a month with email/call support to help guide me.
I am open to making one new habit change a month with email/call support to help guide me.
If I have to, I might.
I am not willing to make an habit or lifestyle changes at this point in my journey.
4.What is your name?
5.What is your best email for a Wellness Consultant to follow up with you?
6.What is your best telephone number for a Wellness Consultant to follow up with you?
7. Please put a check mark next the symptoms you have/had:
Hypothyroidism
Hyperthyroidism
Graves’ Disease
Inflammation
Enlarged Thyroid
Hashimoto’s Thyroiditis
Thyroid Nodules
Cysts
Tumors
Metabolism Problems
Mystery Weight Gain
Mystery Weight Loss
Constant Hunger
Mystery Hair Thinning
Mystery Hair Loss
Change in Hair Texture
Insomnia
Fatigue
Tiredness
Changed in Energy Levels
Brain Fog
Difficulty Concentrating
Memory Loss
Heightened Sensitivity to Cold
Cold Hands and Feet
Chills
Fever
Hot Flashes
Night Sweats
Running Hot
Excessive Sweating
Body Temperature Fluctuations
Edema
Puffy Face
Puffy Eyes
Swollen Hands and Feet
Mood Swings
Irritability
Anxiety
Depression
Restlessness
Restless Legs
Aches and Pains
Headaches
Migraines
Joint Pain
Muscle Cramps
Muscle Weakness
Tingles and Numbness
Twitches and Spasms
Trembling Hands
Heart Palpitations
Ectopic Heartbeats
Arrhythmia
Changes in Heart Rate
Tightness in the Chest
Hypertension (High Blood Pressure)
High Cholesterol
Tinnitus (ringing or buzzing in the ears)
Vertigo
Meniere’s Disease
Dizziness
Balance Issues
Goiter
Throat Tightness
Swollen Tongue
Altered Sense of Taste and Smell
Metallic Taste in the Mouth
Hoarseness or Change in Voice
Brittle or Ridged Nails
Dry, Cracking Skin
Constipation
Diarrhea
Loss of Libido
Gas
Acid reflux
Abnormal Menstrual Periods
Blurry Vision
Eye Floaters
Bulging Eyes
Skin Discoloration
Infertility
Miscarriage
Pregnancy Complications
Breast Cancer
MTHFR Gene Mutation
Injury that Won’t Heal
Fibromyalgia
Chronic Fatigue Syndrome
Eczema
Psoriasis
Lupus
Multiple Sclerosis (MS)
Lyme Disease
Rheumatoid Arthritis (RA)
Connective Tissue Disorders
Sarcoidosis
Shingles
Acid Reflux
Pulmonary Fibrosis, Cystic Fibrosis
Interstitial Lung Disease
Hypoglycemia
Type 2 Diabetes
Streptococcus
Raynaud’s Syndrome
Cushing’s Syndrome
Hepatitis C
Plantar Fasciitis
Parathyroid Disease
Polycystic Ovarian Syndrome (PCOS)
Mucus in throat
Difficulty swallowing
Frequent hoarseness
Tonsilitis
Pressure in ears
Itching ears
Frequent ear infections
Tubes in ears
Hearing hallucinations
Sensitive to loud noises
Sensitive to light
Sensitive to smell
Enlarged glands
Constant clearing of the throat
Throat close up
Low blood pressure
Headaches after meals
Headaches if meals skipped
Headaches frontal area
Headaches back of head
Piercing headaches
Afternoon headaches
Daytime headaches
Headaches relived by eating sweets
Face twitch or ticks
Feeling of sand in eye
Strong light irritates eyes
Cataracts
Eye crusting
Conjunctivitis
Neck glands swelling
Stiffness in neck
Lumps in neck
Swelling in neck
Stuffy in neck
Cuts heal slowly
Bruise easily
Rashes
Pigmentation
Changing moles
Calluses
Bugs love to bite you
Circles under eye
Rashes on skin
Oily skin
Itchy skin
Fungus on nails
Hair loss
Acne
Boils
Peeling skin
Nails split
Fingernails chip, break or peel
Athlete’s foot
Cellulite
Are you sensitive to sun?
Are you sensitive to fabrics?
Are you sensitive to detergents?
Are you sensitive to lotions?
Are you sensitive to creams?
Post nasal drop
No sense of smell
Change of seasons tend to make symptoms worse
Watery nose
Drainage in nose
Bloody nose
Runny/discharging nose
Chapped lips
Fever blisters
Dry mouth
Coated tongue
Sore tongue
Bleeding gums
Canker sores
TMJ
Cracked lips / corners
Dental problems
Breathing heavily
Wheezing
Skipped heartbeat
Heart enlargement
Perimenopause
Menopause
Bloating
Feeling of incomplete bowel movement
Bloody stools
Anal itching
Changes in bowels
Excessive appetite
Gallstones
Gallbladder pain
Liver pain
Bad breath
Anemia unresponsive to iron
Fainting spells
Dizziness
Blackouts/amnesia
Forgetfulness
Convulsions
Pain in mid back region
Considered clumsy
Difficulty falling asleep
Difficulty staying asleep
Early waking
Waking between 2-4am
Unable to fall back asleep after waking in the night
Sleeping 6-8 hours a night
Waking up refreshed
Waking up unrefreshed
Daytime sleepiness
No dreams to recall
Sleepwalker
Nightmares
Snoring
Sleep apnea
Frequent yeast infections
Urinary traction infections
Erectile dysfunction
Sexual dysfunction
Osteoarthritis
Poor immune function
Latex allergy
Hepatitis
Lung cancer
Colon cancer
Ovarian cancer
Prostate cancer
Skin cancer (melanoma)
Skin cancer(squamous)
Gout
Interstitial cystitis
Kidney stones
Type 1 diabetes
Insulin resistance or pre-diabetes
Adrenal issues
Other hormonal related problems
Close product quick view
×
Go to Top