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Free, No-obligation Assessment
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1. How long have you been diagnosed with Parkinson's and what PD side effects
do you have?
2. What Parkinson’s medications are you on and for how long?
3. What other medical conditions do you have and what medications for those
conditions are you currently taking? Include any antibiotics in the last year, if any?
4. Have you been tested for heavy metal toxicity?
 Yes
 No
5. Are you taking any supplements like herbs, Vitamin A, C, etc..? Please list them?
6. Do you suffer from any constipation, bloating or
indigestion?
 Yes
 No
7. What kind of water do you drink (filtered, plastic bottled, tap…etc.) and how
many ounces or 8 oz. glasses per day?
8. Do you use any artificial sweeteners or drink diet
drinks (Diet Coke, gum, candy and baked goods)?
 Yes
 No
9. Give me a general idea of what you are drinking (coffee, beer, wine or mixed
alcoholic drinks).
10. Give me a general idea of what you are eating for breakfast, lunch and dinner,
including snacks.
11. Feel free to share with me anything else you want me to learn about you in
terms of your health background.  
* 12. Best time of day to reach you by phone?
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This free assessment is for informational purposes and not designed to take the place of a
qualified health care professional.  It was created to share with you some basic ideas and
health tips that I have learned to enhance my digestive health and overall well-being.
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Parkinson's Disease
Information for a Healthier Future
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Free, No-Obligation Assessment,
form below or call TODAY
1-800-559-3706, Pacific Time
Before I can give you recommendations, I need to know a little bit more about your lifestyle and health
challenges. Please take a few moments to answer as many of the questions below as possible, so that I can
get a chance to learn more about your health background.  As a result, I can customize an effective
supplement and dietary program for you. Once I have received your filled out questionnaire, I will provide you
the answers by phone as well as by email, if you will leave your phone number on this questionnaire and best
time for me to find you at that number.