AskDrLindsey.com

Welcome to Dr. Lindsey's Health Evaluation Questionnaire. Simply fill in each of the areas below and click submit. You will receive a personal health evaluation from Dr. Lindsey and his team of Nutritional Consultants. Your credit card information will be securely transmitted to the Nutritional Consultants. The $25 processing fee will not be charged until your program is prepared.

Personal/Billing Information
Name: (as it appears on your credit card)
Address:
City:
State:
Province:
ZIP:
Country:
E-mail Address:
Verify E-mail Address:
Telephone Number:
Age:
Occupation:
Sex:	M F

1. What is your main physical complaint or health issue?

2. What inherent weaknesses (genetics) run in your family history?

3. Please list all prescription medications, herbs, and supplements you are currently taking and reason for taking them.

4. Please list any known allergies (allergic reactions) to foods, medications, supplements, etc. (For example, shellfish, dairy, etc.)

5. Please rate the following issues as they pertain to your health.

Questions	No problem	Low concern	Moderate concern	Serious problem

Mental clarity (forgetfulness, brain fog)

Stress level (daily, work, life stress)

Headaches

Backaches and joint pains

Anxiety

Depression

Immune system (do you get sick easily?)

6. How many bowel movements are you having each day?

Are they full and complete movements?

7. How is your energy throughout the day (high, average, low)?

8. Do you experience indigestion after meals? After meals, do you get sleepy, bloated, gassy or have undigested food in stool?

9. How tall are you and how much do you weigh?

If overweight or underweight, by how much?

10. 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?

11. Do you have any history of eating disorders, such as anorexia, bulimia or over-consumption?

12. How many hours of sleep do you get each night?

Do you wake up feeling rested?

13. How many times do you exercise each week?

What type of exercise?

How long?

14. How much alcohol do you consume each day, week or month?

15. Do you use tobacco products?

If yes, what kind and how often?

16. Have you ever traveled outside the U.S. within the past three years?

17. Give an example of an average day of eating, including drinks and any snacks. Estimate your portion sizes (e.g. 1 cup milk, 16 ounces of soda, 1/4 lb. of beef, 2 slices of pizza, etc.)

Breakfast:

Lunch:

Dinner:

Snacks:

Dessert:

Drinks:

18. Do you have any other health-related issues, concerns or comments not yet covered?

19. How did you hear about AskDrLindsey.com?

20. Where do you purchase health-related products (vitamins, herbs, teas, etc.)?
Please include the name and location for any stores you may list.

21. If you have already spoken with an Ask Dr. Lindsey Nutritionist, please indicate here:

22. Please enter your payment information below. We guarantee that you are receiving the highest level of encryption possible. Your credit card account numbers and other confidential information cannot be intercepted or altered. The $25 processing fee will not be charged until your program is prepared.

Credit Card Type:
Credit Card Number:
Expiration Date:
Security Code (CCV):

NOTE: If you would rather phone in your payment information, please call 1-888-323-9355. If you prefer to pay by check or money order, please make it out to Genesis Today for $25, write Ask Dr. Lindsey in the check/money order memo, and mail to:

Disclaimer
The information provided by Genesis Today and Lindsey Duncan ND, CN 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. Genesis Today and Lindsey Duncan ND, CN do 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.

Genesis Today
Attention: Ask Dr. Lindsey
14101 West Highway 290, Building 1900
Austin, TX 78737