Fuel for Life

Contact Information
Name*
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Email*
Questionnaire
Do you have any allergies to medications, plants, animals, or foods?*
Do you use any over-the-counter medication regularly?*
Do you use any vitamins, minerals, herbs, or other supplements daily?*
Do you have asthma or exercise-induced asthma?*
Have you ever had a seizure?
Do you have epilepsy?
Do you have diabetes or high resting blood sugar?*
Are you or have you been anemic?*
Have you been diagnosed with an eating disorder?*
Are you being treated for high blood pressure?*
Do you have or have you ever had heart disease?*
To your knowledge, do you have any family history of heart disease, diabetes, stroke, or other chronic disease (in parents)?*
Do you have or have you ever had lung disease?*
Do you have or have you ever had kidney disease?
Do you have or have you ever had liver disease?
Do you have or have you ever had stomach disease (ulcers, bleeding, etc.)?*
Do you have or have you ever had frequent headaches?*
Have you ever had a head injury?*
Have you ever had a broken bone or fracture?
Have you ever had a surgery?*
When was you late blood work testing done?
Describe your sleep patterns.*
Are you taking birth control?*
Please choose:*
Other Information
The above questions have been answered correctly and truthfully to the best of my knowledge.*
- Yes

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