If there was one thing you could change about your health, what would It be? You Family Friend You Famniy Friend roms 0 00 Asthma/Bronehitis ° 0 0 Constipation © © O_Respratory irfammation © 0 0 cers © 0 © Frequent infection FusColds © 0 0 sine High Histamine Levee/Sinos Prob- ye Gout 0 0 0 leme 2 0 0 Diabetes © 0 0 Parknson's 9 0 0 Address: High insulin Needs 0 0 0 Veiga Dizziness) 2 0 0 Diabetic Retinopathy © 0 0 Headache Pain 0 0 0 city, sn_zm, Macular Degeneration 0 0 0 Altheimers 2 0 0 — Catarats/Glaucoma © 0 Carpal Tunnel Pain 2 0 0 i Vascular Disease 0 0 0 AS © 0 0 bienistond Weak Arteries and Veins © 9 0 ADDIADHO. 0 0 0 Good Celular ColagervElascty © OO Fibromyalgia © 0 0 Phone (eve) PoorLower Lag ood Vaume QO OMS. 0 0 0 Poor Greuation © 0 _LowEnergy & Stamina 2 0 0 malt, High Blood Pressure 0 0 Chronic Faigue 2 0 0 Poor Capitan | © 0 0 Lupus 0 0 0 Fat Formaton/Cotutte © 0 0 Immune Defiseney © 0 0 Do you take wtanins? Yes No Varicose Veins 0 0 0 Hepatitis © 0 0 Prlediis © 6 0 High Cholestert © 0 0 Rough Skin 0 0 0 Hemonthoide/rostate Prctions = «OO ‘re you familar with ANT-ONIDANTS anda they Brusing/Cracking Sn © 0 0 Menopause/PNSICramps © 0 0 or Yes No Eczema © 0 0 _Agngconcems © 0 0 Peonasie © 0 0 Canoer Rae 0 0 0 Damaged Artery Lining © 0 0 _ Environmental Concems 20 0 0 sein Floste © 0 0 Winding ofthe Skin eo 0 0 ‘antes ifammaionPain = «0 Paion o 0 0 ‘Sports Inuies 0 0 0 Smoke 2 0 0 ayer Muscle Cramps 0 0 0 bngs © 0 0 ee seats ete eens eitioetes. ‘assovaled wit FREE RADICALS and thelr ‘Alergiestay FeveriAlergic Re- ‘foots on our bodies? Yes No ‘sebone © 0 © AllFres Radios! Damage 0 0 0 Is there any reason you would not be willing to use a product that would address these concerns? YES__NO_