Veo Natural Healthy and Wellness Survey

Personal Information
Name *
Name
Gender *
Feet, Inches (i.e. 5, 9)
In Pounds
Do you exercise more than 3 times/week? *
Do you smoke, use nicotine products, or live with someone who does? *
Do you drink alcohol? *
Do you find it difficult to work under pressure? *
Do you suffer from skin rashes? *
Do you suffer from acne? *
Have you ever taken steroid drugs for allergies, asthma, or injuries? *
Is your eyesight getting worse? *
Are you using birth control or taking synthetic hormones? *
Do you drink less than a Quart of filtered, spring, or mineral water for every 50 lbs. or body weight per day? *
Do you have difficulty seeing at night? *
Do you have white spots on your fingernails? *
Do you have high blood pressure? *
Do you ever get light headed or dizzy? Do you get short of breath easily? *
Do your ankles swell? *
Do you experience leg nervousness or "twitching" at night? *
Do you have severe fatigue and find it hard to get up in the morning? *
Do you have generalized low energy or feel tired? *
Do you need caffeine or other stimulants to get you going? *
Are you overweight or have you gained weight recently? *
Do you have dry skin, thinning hair, dry or brittle nails? *
Do you suffer from mood swings and/or do you cry easily? *
Do you have low sex drive? *
Do you have trouble thinking clearly, concentrating, foggy thinking, and/or short-term memory loss? *
Do you have high cholesterol? *
Is your skin yellow? *
Do you often feel sad or depressed? *
Do you find it difficult to relax? *
Do you lose your temper easily? *
Do you suffer from insomnia or have difficulty sleeping? *
Do you have excessive thirst? *
Do you have headaches? *
Do you get tense if you do not eat on time? *
Do you get tired before you eat? *
Do you get tired after you eat? *
Do you get tired after you eat sweets, sugar, or carbohydrates? *
Women's Health (if Male answer 'No' to all)
Do you suffer from Pre-Menstrual Syndrome (PMS)? *
Do you have painful menses, irregular or an abnormal menstrual cycle (periods)? *
Are you in "Menopause"? *
Are your breasts overly sensitive or "painful" before, during, or after menses? *
Are your menstrual cycles irregular? *
Do you produce vaginal discharge? *
Do you have menopausal "hot flashes"? *
Do you have acne or other skin blemishes that worsen during menses? *
Do you have itching or burning of the vagina or rectum? *
Male Health (if Female answer 'No' to all)
Do you have frequent urination, trouble urinating, or do you “dribble” i.e. can't stop completely? *
Do you have premature ejaculation? *
Have you experienced or are you experiencing prostate trouble? *
Do you often wake up during the night to urinate? *
Do you feel like a "couch potato" and lack the drive or zest for life? *
End of Gender Specific Sections
Would you call yourself a worrier? *
Do you feel like you have a lot of stress?
Do you take downtime to recharge your batteries?
Do you lack taking a multivitamin on a daily basis? *
Are you frequently anxious, depressed, or have panic attacks? *
Would you rate yourself as being "stressed out"? *
Have you ever experienced any major life stresses in the past year? *
Do you eat meat, commercially baked sweets, fried foods, or use vegetable oil daily? *
Do you consume fatty or oily fish (salmon / mackerel) less than two times per week? *
Do you use chemical cleaners or solvents at home, at work, or in your hobbies? *
Do you have amalgam (mercury) fillings? *
Are you prone to side effects from medications or supplements, or have you become more sensitive to the effects of alcohol or caffeine (reduced tolerance)? *
Do you have fewer than 2 bowel movements per day? *
Do you or have you every had breast implants? *
Do you consume “diet foods” sweetened with aspartame, Splenda, or saccharin? *
Do you become physically ill when exposed to strong smells (perfume, auto-exhaust, cigarette smoke, etc.)? *
Do you have an excessive consumption of soda or coffee (more than two cups a day)? *
Do you cook or re-heat foods in plastic containers in the microwave? *
Do you live or work in an environment that re-circulates the indoor air (commercial travel more than once per month)? *
Do you use pesticides on your property? *
Do you have any pets, especially dogs, cats, birds, or other furred or feathered animals? *
Do you suffer from allergies, arthritis, fibromyalgia, or asthma? *
Do you have an increased susceptibility to common cold and flu, sore throat or a respiratory infection that hangs around for months? *
Do you have a chronic cough, scratchy throat, sinus congestion, or excess mucous production, making it necessary to clear your throat often and/or have ear problems? *
Do you have a stuffy nose even when you do not have a cold? *
Have you ever been diagnosed with an autoimmune disease? *
Do you have dark circles under your eyes? *
Have you been vaccinated? *
Have you or anyone in your family served in the military in the past 15-20 years? *
Do you have white thrush or yellow fuzzy tongue? *
Do you have athlete’s foot, ringworm, or jock itch? *
Have you ever taken antibiotics? *
Do you swallow your food prior to chewing your food completely, or eat too fast? *
Do you tend to overeat? *
Are you troubled by heartburn or acid reflux? *
Do you have intestinal gas/bloating and or frequent belching? *
Do you experience constipation or diarrhea? *
Does it feel like it takes a long time for food to digest? *
Do you experience digestive problems when eating fatty or greasy foods? *
Do you suffer from nausea? *
Do you have poor appetite? *
Do you regularly include fast food in your diet (three or more times per week)? *
Do you feel fatigued or lethargic after eating? *
Do you commonly have bad breath or a bad taste in your mouth? *
Do you use digestive aids such as laxatives, antacids, or acid-blocking drugs? *
Do you often feel "older" than you should for your age? *
Does your skin look sallow, gray, puffy, wrinkled, or aged? *
Do you suffer from joint problems, arthritis or muscle aches? *
Have you sustained an injury to some part of your body in the last 24 months? *
Have you been involved in a motor vehicle accident? *
Do you sprain or re-injure the same body part over and over? *
Do you feel your range of motion or flexibility is not what it used to be? *

Disclaimer: This General Health Questionnaire is not intended to diagnose, treat, cure or prevent any disease. None of the statements herein have been evaluated by the FDA nor are any endorsement thereof implied or given.


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