Home  |  Product Search  |  Site Map  |  Checkout  |  Track Your Order 
 
Supplement Categories

Supplement Categories

Items Ordered

Items Ordered

Name:

Name:


Email

Email


Which medications, if any, do you currently take that has restrictions

Which medications, if any, do you currently take that has restrictions


What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol?

What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol?

(Please give exact number, if not sure please put "not sure")

What is your total cholesterol number?

What is your total cholesterol number?

(Please give exact number, if not sure please put "not sure")

What is your triglyceride number?

What is your triglyceride number?

(Please give exact number, if not sure please put "not sure")

Are you on cholesterol medicine?

Are you on cholesterol medicine?

(Please list all)

Have you ever had hepatitis or cirrhosis of the liver?

Have you ever had hepatitis or cirrhosis of the liver?

(Please list all)

Symptoms of a pH imbalance -- acidosis or alkalosis

Symptoms of a pH imbalance -- acidosis or alkalosis

Do you happen to know your saliva and urine pH? If so please put here

Symptoms of a Glandular Weakness

Symptoms of a Glandular Weakness

What is your body temperature ? (Give Exact number in Fahrenheit, do not put normal)

How many moons do you have on the bottom of your fingernail cuticles?

Symptoms of Yeast Overgrowth

Symptoms of Yeast Overgrowth

Have you taken antibiotics or birth control?

Symptoms of a Weak Digestion

Symptoms of a Weak Digestion

Do you burp more than 2 times a week? (not including after drinking soda)

If you have been diagnosed with a lung disease, what is the name of the disease?

Have you every been diagnosed with a disease or health condition? If so please list all.

Are you on any medication which has diet or supplement restrictions? If so please list.

Are you on a blood thinner or have a bleeding disorder?

Are you on SSRI's?

What is your birth date? MM/YR*

What is your birth date? MM/YR*


What is your email?

What is your email?


If you have a discount coupon, please enter coupon # here*

If you have a discount coupon, please enter coupon # here*


How did you hear about us?

How did you hear about us?


Copyright © 2010 Dr. Mary Reed Gates, CNHP, MH, ND, Lancaster, PA
MarysHerbs
@aol.com