Part 1

Please list your 5 major health concerns in order of importance:

Part 2 - Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Category II

Category III

Category IV

Category V

Category VI

Category VII

Category VIII

Category IX

Category X

Category XI

Category XII

Category XIII

Category XIV

Category XV

Category XVI

Category XVII (Males Only)

Category XVIII (Males Only)

Category XIX (Menstruating Females Only)

Category XX (Menopausal Females Only)