blmd gea Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *DOBMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeOur goal is to improve the Health and Wellbeing of every patient! Medical & Scientific technology has provided us with tools to practice a more precise, personalized and predictive approach to your individual health and Wellness. Recent studies have shown that many health conditions, symptoms, and diseases are caused by changes in Epigenetic marks or gene expression. This Genetic Expression Assessment is a vital first step to identify and address your epigenetic expression health goals for optimal wellness. When genes aren’t expressing themselves optimally, symptoms and health issues occur. As such, when the expression is enhanced, optimal health occurs! Epigenetic Signal Detection Technology may determine appropriate nutritional and lifestyle interventions that may help to improve, or address symptoms indicated. Answer the following questions to the best of your abilities based on your experiences presently and/or within the past six months.Your Nutritional Health such as Vitamins, Minerals, Amino Acids, Fatty Acids, Antioxidants are directly linked to your Genetic Expression. Imbalances, deficiencies or inadequate sources of these vital nutrients, cause Genetic Marks and Expression to be affected. This creates symptoms and conditions that inhibit your overall optimal wellness. Below are some key Vital Nutrients that may influence symptoms. This assessment is vital to becoming proactive in achieving optimal health and wellness. SYMPTOMS“X” NEVER “X” SOMETIMES“X” FREQUENTPOTENTIAL VITAL NUTRIENT IMBALANCES (not all listed)1. Weight gain/obesity NeverSometimesFrequentAlpha Lipoic Acid, CO-Enzyme Q10, Anthocyanidins2. Insomnia or frequent waking NeverSometimesFrequentB3, Polyphenols, Glycine, Tryptophan, D33. Arthritis / Aching jointsNeverSometimesFrequentCopper, Manganese, Sulphur DHA-3, EPA-3, Histidine, CO-Enzyme Q10, Valine4. Sore muscles and/or swollen joints NeverSometimesFrequentD, Manganese, CO-Enzyme Q10, Potassium5. Depression/Anxiety /Mood Swings / Irritability / ObsessivenessNeverSometimesFrequentB5, B6, D3, Lithium, DHA, Serine, Cysteine, Chromium6. Blood sugar spikes and crashesNeverSometimesFrequentAnthocyanidins7. GI Disorders/Acid reflux/heartburn /IndigestionNeverSometimesFrequentB3, E, Potassium, GLA-6 Glutamine, AA-6,8. Constipation or DiarrheaNeverSometimesFrequentPotassium, Alpha Lipoic Acid9. Cravings especially carbs or sugarNeverSometimesFrequentGlutamine, Tryptophan10. Blurred Vision NeverSometimesFrequentALA11. Bruising NeverSometimesFrequentK1, K2, C, Flavonoids12. Headaches/migraines / Brain FogNeverSometimesFrequentB3, B9, Glycine,Leucine,Phytoestrogen13. Gas and bloating / Food Intolerance NeverSometimesFrequentAA-6, B314. Itchy skin or scalp / Skin Rash /Acne NeverSometimesFrequentCarotenoids, Zinc, Arginine, Histidine, Oleic-9, B615. Dry skin or oily skin NeverSometimesFrequentB2, C, Zinc, ALA, Eion, Oleic16. Thinning or brittle hairNeverSometimesFrequentCalcium, Selenium, AA-6, Eion, GLA-6SYMPTOMS“X” NEVER“X” SOMETIMES“X” FREQUENTPOTENTIAL VITAL NUTRIENT IMBALANCES (not all listed17. Hot or Cold Flashes/Hormonal Imbalance / SweatingNeverSometimesFrequentPhytoestrogen18. Tremors / Poor Coordination / Muscle SpasmsNeverSometimesFrequentMagnesium, Sodium, E, Calcium19. Cold hands & feet / Tingling/ NumbnessNeverSometimesFrequentALA, Potassium, Linoleic, B1, Iron20. FatigueNeverSometimesFrequentB2, B5, D3, Calcium, Selenium Copper, Iron, Chromium21. Wake up starving NeverSometimesFrequentTryptophan, Glutamine22. Excessive appetite (high or low)NeverSometimesFrequentMagnesium, Phosphorus, Zinc23. Do you diet and find it hard to keep off excess weight?NeverSometimesFrequentPhenylalanine, Tryptophan, Alpha Lipoic AcidSYMPTOMS“X” Yes“X” NoComments24. Do you have frequent runny nose/congestion?YesNo25. Do you suffer from allergies?YesNo26. Please list any known food allergies.27. Are you presently taking nutritional supplements?YesNoComments28. Do you practice intermittent eating or fasting?yesNoComments29. Do you ever have unexplained symptoms/just not feeling right? YesNoComments30. Do you have any other further health or wellness concerns you’d like to address?CommentSubmit
