structure Name * First Name Last Name Email * Phone * (###) ### #### Message Do you feel you are getting shorter over time? * Yes No Have any back problems? * Yes No Do you frequently get a sore neck? * Yes No Are you a frequent cell phone user? * Yes No Have you been told that you have elevated hemoglobin Ale? * Yes No Do charbroiled foods show up frequently in your diet? * Yes No Any memory problems? * Yes No Do you have a weight problem even though you watch your calories like a hawk? * Yes No Is your waist-to-hip ratio greater than 1? * Yes No Do you eat a lot of foods and drinks stored in plastic containers? * Yes No Are you one of those people who are 'cold all the time'? * Yes No Have you been told you have reduced bone mass? * Yes No Are you menopausal? * Yes No Do you pretty much avoid dairy products? * Yes No Do you eat proportionally way more animal protein than vegetables? * Yes No Thank you!