Name:
Email address:
City, State/Country:
Year of birth:
Weight:
Male or Female:
List the health problems that bother you most in descending order.
Do you think you’re eating healthy food?
Good appetite? Any food you tend to eat too much?
Do you have a long list of food you’re allergic to?
Sleep ok? Easily disturbed in your sleep?
Are you active or do you exercise enough everyday?
Do you have any bad habits that may impact your health?
Good energy in the morning? Can you recover easily after some rest?
Used to feel cold, especially hands and feet?
Are you impatient? Can you bear standing in line?
Do you have high blood pressure, high cholesterol, or diabetes?
Thank you! Please email this completed questionnaire to:
askjohnfung@comcast.net
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