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Submitting Your Audition Form

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Question 1 of 24

Please enter your first and last name.

Question 2 of 24

Please provide your email address.

Question 3 of 24

Please provide your Date of Birth (DD/MM/YYYY)

Question 4 of 24

Please select your age group.

A

35-45

B

46-55

C

56-65

Question 5 of 24

What's your current occupation, or what was your occupation?

Question 6 of 24

Please provide your mailing address.

Question 7 of 24

Please provide your phone number.

Question 8 of 24

Please provide your skype name.

Question 9 of 24

Please provide your current weight.

Question 10 of 24

Please provide your current height.

Question 11 of 24

What is your primary health concern?

Question 12 of 24

What symptoms are you experiencing regarding your primary health concern?

Question 13 of 24

When did your primary health concern begin?

Question 14 of 24

What is your secondary health concern?

Question 15 of 24

What symptoms are you experiencing regarding your secondary health concern?

Question 16 of 24

When did your secondary health concern begin?

Question 17 of 24

Medical History Review (A) - Please select all problems you currently have, or have ever had.

(Select all that apply)
A

Abdominal Pain

B

Acne

C

Allergies (Environmental)

D

Allergies (Food)

E

Antibiotics Use

F

Arthritis (Rheumatoid)

G

Anorexia/Bulimia

H

Alcoholism

I

Appendicitis

J

ADD/ADHD

K

Anemia

L

Asthma

M

Bruise Easily

N

Bad Breath

O

Bloody Stool

P

Bronchitis

Q

None of the above

Question 18 of 24

Medical History Review (B) - Please select all problems you currently have, or have ever had.

(Select all that apply)
A

Chronic Diarrhea

B

Chronic Fatigue

C

Candidiasis

D

Cancer

E

Celiac Disease

F

Crohn’s Disease

G

Constipation

H

Depression

I

Diabetes I

J

Diabetes II

K

Excessive Gas

L

Excessive Thirst

M

Endometriosis

N

Epilepsy

O

Fibromyalgia

P

Gout

Q

Gallstones

R

None of the above

Question 19 of 24

Medical History Review (C) - Please select all problems you currently have, or have ever had.

(Select all that apply)
A

Glaucoma

B

High Blood Pressure

C

Heart Attack

D

Heart Arrhythmia

E

Headaches

F

High Cholesterol

G

Hyperthyroidism

H

Hypothyroidism

I

IBS

J

Insomnia

K

Joint Pain

L

Kidney Disease

M

Kidney Failure

N

Low Blood Pressure

O

Liver Disease

P

Menopause

Q

None of the above

Question 20 of 24

Medical History Review (D) - Please select all problems you currently have, or have ever had.

(Select all that apply)
A

Multiple Sclerosis

B

Muscle Cramps

C

Numb hands or feet

D

Nausea

E

Nervousness/Anxiety

F

Osteoarthritis

G

Osteoporosis

H

Peptic Ulcer

I

Poor Appetite

J

Post Nasal Drip

K

PMS

L

Psoriasis

M

Smoker (# of years)

N

Sinus Problems

O

Stroke

P

Unintentional Weight Gain

Q

Unintentional Weight Loss

R

None of the above

Question 21 of 24

Please disclose any Diagnosed Mental Health Conditions here. If none, please fill in "None".

Question 22 of 24

Please list any food allergies, intolerance or sensitivities.

Question 23 of 24

Please list all of the supplements you are currently taking.

Question 24 of 24

Please list all of the medications you are currently taking.

Confirm and Submit