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Welcome to our Free Health Evaluation Questionnaire. Simply fill
in each of the areas below and click submit. You will receive a personal
health evaluation by e-mail shortly.

AFTER submitting your form, you will be automatically redirected to the our HOMEPAGE.
DO NOT fill out a new Form.

You will receive an email with CONFIRMATION.

Do you need to detox? Click HERE to take Detox test.

CLEANSING PRODUCTS

Name:
Age:
Gender:
Address:
City and STATE:
Zip Code:
Telephone:
Employment/Type of Work:
Email:
Verify Email:
What is your main physical complaint or health issue?
What inherent genetic weaknesses run in your family history?
Please, list all prescription medications and herbal supplements you are currently taking and the reason for taking them.
Please, check the box that best describes your health in regard to the following conditions: Mental clarity
Headaches:
Stress level (Daily, work, liffe, stress)
Backaches & Joint Pains:
Anxiety/Depression:
Immune system (Do you get sick easily?):
How many bowel movements are you having each day? Specify how many a day or week.
Are they full and complete movements?
Have you ever done a cleansing/detoxification program before? How long ago and how did you do it?
How is your energy throughout the day (high, average or low)?
Do you experience indigestion after meals? After meals, do you get sleepy, bloated, gassy or have undigested food in stool?
Are you at your ideal weight, underweight, or overweight?
If overweight or underweight, how much?
Do you exercise? How often? How long?
Describe the condition of your skin. Do you have normal skin or do you have problems with acne, wrinkles, dry skin, rashes or signs of premature aging?
Do you have any history of eating disorders, such as anorexia, bulimia or over-consumption?
How many hours of sleep do you get each night?
Do you wake up feeling rested?
How much alcohol do you consume each day, week or month?

Give an example of an average day of eating, including drinks and any snacks.

Breakfast:

 
Lunch:
Dinner:
Snacks:
Dessert:
Drinks:
Do you have any other health related issues, concerns or comments not yet covered?
How did you hear about www.genesistodayonline.com?
Where do you purchase health related products (vitamins, herbs, teas, etc.)?

AFTER submitting your form, you will be automatically redirected to the our HOMEPAGE.
DO NOT fill out a new Form.

You will receive an email with CONFIRMATION.

Disclaimer
The information provided by this website is not medical advice and is not intended to take the place of the care provided by your Medical Doctor. This information is provided for educational purposes only and the intention is to help educate on diet improvements, lifestyle improvements and nutritional supplementation. My Genesis Now do not not treat, diagnose, prescribe for, or cure any disease, disorder, deformity or physical or mental condition. Because we are all so different, individual results may vary. Always consult your Doctor prior to starting any new health program.