Name *

First Name

Last Name

Age *

Please tick your age range

18-25

25-30

30-35

35-40

45-50

50-55

55-65

65-75

75+

1. Your mother told you that your birth was traumatic, or you were a c-section baby.

Yes

No

2. When you were a child you had poor coordination and didn't like athletics.

Yes

No

3. You were fed mostly formula as an infant.

Yes

No

4. You worry a lot and often have anxiety.

Yes

No

5. As a child, you had a lot of sudden emotional outbursts.

Yes

No

6. When you were a child, you were more of a logical thinker and you are analytical.

Yes

No

7. You tend to have a lot of allergies.

Yes

No

8. You tend to have digestive problems like constipation, or diarrhea, bloatedness, and stomach pains.

Yes

No

9. You have tense shoulders and frequent neck pain, especially when you're stressed.

Yes

No

10. You chronically don't sleep well.

Yes

No

11. Your fine motor skills, like handwriting or buttoning a shirt has been weak, especially as a child.

Yes

No

12. You sit at a desk all day at work and your know your posture is not good.

Yes

No

13. As a child, you often had ear infections.

Yes

No

14. You often have 'brain fog' for no reason.

Yes

No

15. You have been in a car accident in the past, even a fender-bender.

Yes

No

16. You're always tired with very low energy to keep you going through the day.

Yes

No

17. You have recurrent headaches and you need to pop pain pills often just to help you focus.

Yes

No

18. When you were a child, you made decisions based on your sense of things and your feelings, rather than logic and analysis.

Yes

No

19. You get severe coughs every year and you often take antibiotics to get rid of your symptoms.

Yes

No

20. You're sick and tired of feeling like crap.

Yes

Yes!

I'm fed up!