Food Allergy Survey - Health Investment Group

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Food Allergy Survey

Do you have unexplained health problems?

Complete the survey below
and receive an analysis of your
body's response to
food allergens!

Check all that apply

#1 Do you have: *

Knee, Shoulder, Joint Pain Back Pain, Neck Pain Stiff shoulders, Headaches Numbness, foot/arm fall asleep Trouble getting to sleep Bleeding gums, cavities Kidney Stones, bone spurs High or low blood pressure I take pain killers for above I take blood pressure meds None of the above

Check all that apply

Anything else you would like to improve about your health? *

More energy Lose weight Greater stamina Prevent cancer Slow the aging process Prevent hereditary heart disease None of the above

#2 Do you have: *

Dry Skin, dry cuticles Skin allergies Cracks on your heels Forget things you go get Can't remember a specific word Trouble breathing Cough, dry throat Tiredness, Kidney problems Eye or eyesight issues Ages spots, blemishes Grey hair, wrinkles, early aging I take Cholesterol meds I take blood thinners I take hormones I take Fibro/MS medication I take diuretics I take Alzheimer, ALS, Parkinson meds None of the above

Check all that apply

#3 Do you have: *

Cravings for sugar, sweets Get sleepy after meals Excessive thirst or sweating Sweat after eating Wake up during the night Become weak if you don't eat I take blood sugar medication I take depression meds I take meds for ADD/ADHD None of the above

Check all that apply

I would like to be... *

Pain Free NOT moody or sad More optimistic More patient More courageous More outgoing More confident None of the above

#4 Do you have: *

Heart burn/Acid reflux Stomach/intestinal pain Bloating/gas Food allergies Seasonal allergies Constipation or Diarrhea Immune System Problems I feel better when I don't eat I take Ant-Acids or stomach meds I take meds for Chron's disease I take immune system meds I take fiber/medication for constipation None of the above

Check all that apply

* Indicates required field

Where do you want us to send
your analysis?

Name *

First

Last

Phone Number *

Email *

Who referred you? *

Send me my Free PDF analysis!

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