Check the box next to every question if your response is YES. If in doubt or if you feel like answering „sometimes“, do not check the box. 1. Do you eat meat and/or delicatessen meats more than 5 times a week? 2. Do you eat frozen food and/or canned food more than twice a week? 3. Do you eat 2 or more dairy products per day: milk, yogurt, cheese and/or dishes containing dairy products? 4. Do you eat fatty fish (salmon, sardines, tuna, mackerel...) at least once a week? 5. Do you use extra virgin 1st cold-pressed olive oil as salad dressing? 6. Do you use other virgin 1st cold-pressed oils (colza, sunflower...)? 7. Do you eat regularly, or more than twice a week, ready cooked dishes (pastries, croissants, quiche, take aways...)? 8. Do you eat fast food, in canteens or restaurants more than 3 times a week? 9. Do you eat more than 2 of the following per day: biscuits, cakes, cereal bars, refined sugar (2 cubes), sodas or bottled fruit juices? 10. Do you eat fresh fruit or at least one portion of raw vegetables per day? 11. Do you eat, at least once a day a portion of fresh cooked vegetables? 12. Do you eat organic or fresh products from your garden? 13. Do you usually have a heavy meal in the evening? 14. Do you eat at the same time every day and in calm surroundings? 15. Do you miss one of the 3 main meals more than once a week? (breakfast, lunch, dinner) 16. Are you on a low-calory or a restrictive diet? 17. Do you drink more than half a litre of water every day?
30. Do you have joint pains or bone distortion? Are you subject to osteoporosis? 31. Do you have bleeding or inflamed gums? 32. Do you feel the cold? 33. Do you have a craving for sugar? 34. If you miss a meal, or if it is delayed, do you feel tired or irritable? 35. Is your condition worse after a meal (nervous, irritable, anxious, hypersensitive)? 36. Do you often experience nausea, headaches, vertigo? 37. Do you have a stressful life, family or professional problems? 38. Are you tired, anxious, nervous? 39. Do you feel depressed, do you lose motivation or pleasure for what you enjoyed before? 40. Do you find it difficult to fall asleep, troubled sleep, or do you often wake up during the night? 41. Do you suffer from your back on a regular basis? 42. Do you have skin spots, wrinkles which are deep for your age, or a change in skin elasticity? 43. Do you have sight problems, focusing difficulties (cataract)? 44. Do you often suffer from pains like osteo-arthritis? 45. Do you feel you are aging abnormally?
54. Do you have chronic or frequent skin problems (eczema, psoriasis, herpes...)? 55. Do you have white spots on your nails? 56. Do you often feel your skin itching? 57. Are you affected by electro-magnetic pollution everyday? (electrical lines, computer, TV, mobile phone...)? 58. Do you do little exercise (less than once a week)? 59. Do you carry your fat mostly on the superior part of your body (over the waist)? 60. Do you sweat a lot (armpits, feet, hands)? 61. Do you frequently have intestinal pains? Feeling bloated? 62. Do you regularly wake up at 2 AM? 63. Have you ever had to take antibiotics for either longer than a month, or for a shorter time but more than 3 times this year? 64. Do you regularly have genital or anal itching? 65. Do you have tooth decay, mouth ulcers? 66. Do you suffer from cramps or tiredness after a slight effort? 67. Are you subject to regular urinary infections? 68. Is your hair and skin dull? 69. Do you feel tired, irritable, at the same time every day? 70. Do you suffer from weakness, muscular cramps, spasms or tetany? 71. Do you need stimulants like coffe, tea, alcohol? 72. Do you crave for food before meals? 73. Do you have memory deficiency or concentration difficulties? 74. Are you subject to energy loss or periodical nervous exhaustion? 75. Do you feel under-valued or do you lack self-confidence? 76. Did you have to face more than 5 stressful events in the past 12 months? (changes in your work, unemployment, wedding, birth, death of a close person, moving...) 77. Do you remember old events more easily than recent ones? Do you have memory problems? 78. Do you have vertigo, balance disorders, buzzing noises in the ears, or do you feel you don't hear as well as before? 79. Are you taking medication? 80. Have you ever been over-exposed to the sun or have you been sunburnt more than 15 times during your life? 81. Do you have stiff joints? Do you find it difficult to get your muscles and joints moving in the morning?
