Personal Information

Full name

Email address

Telephone number

General Symptoms

Frequent rashes, dermatitis, hives or other skin conditionSickness more than twice a yearFrequent headachesRecurring running nose

Digestive Symptoms

Occasional, unexplained bloatingFeeling of inflammation following certain foodsDaily bloating or stomach crampsDaily diarrhoeaDaily constipation

Fatigue and Tiredness

Feeling tired during the dayTrouble sleepingDifficulty waking in the morning

Female-Specific Symptoms

Diagnosed PCOSMenopausal or post-menopausalIrregular menstrual cycle

Male-Specific Symptoms

Low libidoDifficulty achieving or maintaining an erectionAnabolic steroid use

Lifestyle

Suspected or diagnosed vitamin/mineral deficiencyMultiple vitamin/mineral supplementationTravel to locations with unsafe tap water

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