Date:  * I agree to the terms of the BioRenew Release Form: YesNo PERSONAL INFO First Name:  * Middle Initial: Last Name:  * Email Address:  * Phone:  * Cell: Address:  * City:  * State:  * Zip Code:  *   HEALTH & BACKGROUND Date of Birth:  * Blood Type:  * Height:  * Weight  *   SURGERY Please indicate if and when you had the following removed: Tonsils? NoYes Year: Adnoids? NoYes Year: Appendix? NoYes Year: Other? Year:   SUPPLEMENTS List of Supplements:   PRESCRIPTIONS List of Prescriptions:   HEALTH ISSUES What are your top 3 health issues?  *   SLEEP ISSUES Average hours of sleep per nite: 123456789101112more Quality of sleep 10 is best: 12345678910   OCCUPATION What occupations have you had?  *   FOOD ALLERGIES List allergies or food sensitivities:   DEPRESSION Do you suffer from Depression? NoYes Times per day: Times per week: Times per month:   METABILIC PROFILE Aging 1) Look older than others my age2) Look younger that others my age. Aloofness 1) Cool distant aloof loner slow to make friends.2) Warm open expressive easily makes friends - approachable. Appetite 1) Weak lacking diminished2) Strong excessive enhanced3) Average Chest Pressure n/a2) Tend to get. Climate 1) Love warm hot weather.2) Do well in cold - poor in hot3) Doesn't matter. Cold Sores - Fever Blisters n/a2) Tend to get. Coughing n/a2) Tend to cough most everyday. Cracking Skin (any weather) n/a2) Tend to get. Dandruff n/a2) Tend to get. Desserts 1) Love seeets - need something sweet with meal to feel satisfied.2) Prefer something fatty or salty like cheese chips or popcorn after meals.3) Can take them or leave them. Digestion 1) Poor weak slow.2) Good strong rapid3) Average Eating Before Bed 1) Usually worsens sleep especially if heavy food.2) Usually improves sleep.3) Doesn't matter but heavy snacks are not best. Eating Habits 1) Eat to live.2) Live to eat. Eat often to feel good - be best.3) Average Emotional Expressions 1) Hard to express feelings.2) Easily express feelings. Emotions 1) Beneath surface - under control - non emotional.2) Wear heart on sleeve - others know how I feel. Eye Moisture 1) Tend toward dry eyes.2) Tend toward moist or tearing eyes. Facial Coloring 1) Tend toward pale chalky.2) Tend toward ruddy rosy flushed. Facial Complexion 1) Tend toward dull unclear.2) Tend toward bright clear. Fatty Food 1) Don't care for it.2) Love it - crave it often.3) Take it or leave it. Fatty Food Reaction 1) Decreases energy and well-being.2) Increases well-being.3) Average reaction. Fingernails 1) Tend to be thick hard strong.2) Tend to be thin soft weak. 4 Hours Without Eating 1) Doesn't bother.2) Irritable jittery weak famished or depressed.3) Feel normal hunger. Gooseflesh 1) Tend not to form easily.2) Tend to form easily. Gum Bleeding n/a2) Tend to get after brushing.3) n/a Gum Color 1) Light pale2) Dark pink red Hunger Feelings 1) Rare - passes quickly - can go long periods w/o eating.2) Often hungry - need to eat regularly and often.3) When late for meals only - not between meals usually. Itching Eyes n/a2) Tend to get. Itching Skin n/a2) Tend to get. Juice or Water Fasting 1) Can handle very well - feels good.2) Fasting makes me feel awful.3) React OK - can fast if necessary. Meat Portions 1) Prefer small.2) Prefer large or often.3) Average. Orange Juice Alone 1) Energizes - satisfies me.2) Can make me light-headed hungry jittery shaky or nauseated.3) No ill effects. Potatoes 1) Not real fond of them.2) Love them.3) Average reaction. Red Meat 1) Decreases energy and well-being.2) Increases well-being energy3) Average reaction. Saliva Amount 1) Tend toward dry mouth.2) Excessive saliva. Saliva Texture 1) Tends to be thick.2) Tends to be thin watery. Salty Foods 1) Foods often taste too salty.2) Really crave or love salt on foods.3) Average use. Skin Healing 1) Cuts heal slowly.2) Cuts heal quickly.3) Average healing times. Skin Moisture 1) Tend toward dry skin.2) Tend toward oily/moist skin.3) Average skin moisture. Skipping Meals 1) Can skip with no ill effects.2) Must eat regularly or often.3) Can get by w/o eating but really feel best eating 3 meals/day. Snacking 1) Rarely or never want snacks.2) Want to eat between meals. Sneezing - any time n/a2) Tend to sneeze every day. Sour Foods - Vinagar Pickles lemons saurkraut yogurt 1) Don't care for want or crave.2) Really like.3) Sometimes like. Sweets 1) Can do fairly well on.2) Don't do well on - sweet foods can seem too sweet.3) No noticeable bad effect. Vegetarian Meal 1) Is satisfying.2) Not satisfying - hungry soon after.3) OK but not really satisfying. Wheezing n/a2) Tend to get. If I eat MEAT for Breakfast 1) I get tired sleepy lethargic and/or very thirsty by midmorning.2) I feel great energetic good stamina / keeps me going until lunch.3) It's OK but not in large portions. If I eat MEAT for Lunch 1) I get tired sleepy lethargis and/or lose my energy in the afternoon.2) I feel great energetic/ good stamina/ no hunger before dinner.3) It's OK but not in large portions. If I Feel Low on Energy 1) Fruit pastry or candy restores. Meat or fatty food tires me.2) Meat or fatty food restores. Fruit pastry or candy makes me worse.3) Pretty much any food restores my energy. In a Social Setting I'm.. 1) Introverted shy quiet non-talkative.2) Extroverted social expressive easily make conversation.   Metabolic Scoring   Number of 1's Selected  * Number of 2's Selected  * Number of 3's Selected  *   Do not enter anything in this field:

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