What is the status of your health and well-being?
Life is busy and sometimes we don’t have time to stop and reflect on our health!

And sometimes, we accept less than optimal health as the new "normal".

This survey is a quick self-reflection exercise to figure out how much your symptoms are affecting your overall health and well-being.

Please enter your email address to receive a copy of your results. We promise not to give away your information or send you anything else:

Email address *
In general, would you say your health is: *
Compared to one year ago, how would you rate your health in general at this time? *
During the past 4 weeks, have you had any of the following problems with your work or other regular activities as a result of your physical health? *
Yes
No
Cut down on the amount of time you spent on work
Accomplished less than you would like
Were limited in the kind of work or other activities
Had difficulty performing the work or other activities (For example – requiring an extra effort)
Cut down on the amount of time you spent on social activities with family, friends, neighbors or groups.
How TRUE or FALSE is each of the following statements to you? *
Definitely True
Mostly True
Don’t Know
Mostly False
Definitely False
I seem to get sick easier than other people
I am as healthy as anybody I know
I expect my health to get worse
My health is excellent
Which of the following symptoms have you had in the past month? (check all that apply) *
Required
On a scale from 1-10, how badly are these problems affecting your life? *
None
Severly affecting my life
On a scale from 1-10, how committed are you to getting better? *
Not Committed
Extremely Committed
First Name (optional)
Your answer
Would you like to join our mailing list for more information about our solutions and valuable information about Food Sensitivities? *
Would you like to speak with someone from Food Sensitivity Solutions about your results? *
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