In which state do you live?: select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Your height: feet inches - Your weight: pounds
Do you smoke?: yes no - Do you drink alcohol?: never rarely occasionally frequently

Do you eat "junk" or fast food?: never rarely occasionally frequently
Do you drink soda containing high fructose corn syrup?: never rarely occasionally frequently

What type of diet do you eat?:
omnivore - (eats anything and everything)
lacto-ovo vegetarian - (vegetarian, with dairy and eggs)
lacto vegetarian - (vegetarian, plus dairy, no eggs)
ovo vegetarian - (vegetarian, plus eggs, no dairy)
semi vegetarian - (vegetarian, plus eggs, dairy and fish)
vegan - (no animal products whatsoever)
raw vegan - (raw vegan - no cooked food)
other - please explain:

For how long have you been eating this type of diet?: years

What is your level of activity? 1 is sedentary and 10 is working out at the gym every day for 30 minutes: select one 1 2 3 4 5 6 7 8 9 10

In what age group are you?: under 18 19-30 31-40 41-50 51-60 61-70 71-80 81-90 over 90

What serious ailments do you have now?:

Cancer HIV/AIDS kidney disease liver disease bowel disease heart disease stroke asthma emphysema candida
rheumatoid arthritis osteo arthritis osteoporosis
eye disorders - If checked - please describe:

skin disorders - If checked - please describe:

allergies - If checked - please describe:

other serious ailments - If checked - please describe below:


What serious ailments have you recovered from?:

Cancer kidney disease liver disease bowel disease heart disease stroke asthma emphysema candida
rheumatoid arthritis osteo arthritis osteoporosis

eye disorders - If checked - please describe:

skin disorders - If checked - please describe:

allergies - If checked - please describe:
Please describe other serious ailments you have recovered from:

How long have you been free of serious ailments?: years

How many days have you been sick with colds, flu or other minor ailments during the past year? days

Additional information you would like to add:


May we contact you? yes no
Name: optional
E-mail address: optional

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