assimilation - elimination Name * First Name Last Name Email * Phone * (###) ### #### Message Do you alternate between constipation and urgency? * Yes No Do you get indigestion? * Yes No Does your stool have an oily apperance? * Yes No Do you suffer from frequent intestinal gas or bloating? * Yes No Is stomach or intestinal pain a regular occurrence? * Yes No Are headaches a common occurrence? * Yes No Are you allergic or sensitive to many foods? * Yes No After eating, do you find you experience joint or muscle pain? * Yes No Do you have bad breath? * Yes No Are you depressed or subject to mood swings? * Yes No Do you have trouble keeping your weight under control even though you watch your diet? * Yes No Is your blood sugar elevated? * Yes No Do you suffer from kidney stones? * Yes No Is your blood pressure higher than it should be? * Yes No Thank you!