Female Quiz – Missing Minerals

Missing Minerals

Dr Ricky D
Boron
Nu Stems
Launch 500

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Scientifically proven to increase Stem Cell's, Signaling, Growth and Proliferation.

Name *

First

Last

Email *

Email

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Phone Contact *

Multiple Choice *

Under 18 years
18 to 45 years
45 to 65 years
Over 65 years

Briefly list health problems and symptoms of concern

List any allergies (food, chemicals, pollens, etc.)

Immune System

Colds / Flu per year
Sinus problems
Swollen lymph nodes
Sore throats per year
Pimples
Snoring
Re-occuring pneumonia
Re-occuring bronchitis
Cough a lot
Hay fever
Cold sores

Cardiovascular System

High blood pressure
Low blood pressure
High cholesterol
Arythmia
Dizziness
Breathlesness
Palpitations
Cold hands and feet
Easy bruising
Varicose veins
Nose bleeds

Musculoskeletal System

Aches and pains
Joint pain
Joint flexibility
Joint swelling
Muscle cramps / twitching
Headaches
Disc Herniation / protrusion
Sciatica

Urinary System

Frequent urination
Dribbling after urination
Strong and sudden urge to urinate
Frequent bladder infections
Pain or burning urination
Incontinence

Metabolic System

Sugar cravings
Weakness
Fatigue
Brittle hair
Weight gain
Weight loss
Sensitive to heat
Sensitive to cold
Increased thirst

Reproductive System

PMS / PMT
Bloating
Fluid retention
Menopausal problems
Hot flushes
Currently pregnant
Currently breastfeeding
Thrush
Low libido

Skin

Acne
Eczema
Dermatitis
Poor wound healing
Dry skin
Dandruff

Rate your energy levels most days *

Low / sluggish
Average
Heaps of energy

Rate your stress levels most days *

Easily stressed
Manage stress well
Have no stress

Rate your sleep most nights *

Good sleep
Sufficient sleep
Poor sleep

Do you smoke? *

Yes
No

Do you regularly exercise? *

Yes
No

Do you drink alcohol regularly? *

Yes
No

Do you eat organic foods regularly? *

Yes
No

Does your diet include a lot of nuts? *

Yes
No

Newsletter *

I would like to receive email updates regarding health talks, health tips and information
No thanks

Agreement *

I agree to the above information is correct and consent to this information being used by the health services to create a product to suit my needs.

All information and discussions remain under the strictest of confidentiality. No information is ever handed onto any third-party companies. This information is stored by this websites for health compliance. I agree that all of the information given in this form is true and correct. I make a commitment to my health and wellbeing today, and understand that the more open I can be, the more I shall get out of this.