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Bio Chemistry Health Questionnaire - page 1

Thank you for taking a step toward greater health!  Completing the 3 page Bio Chemistry Questionnaire below is a great way to identify which organs, glands and body systems need more support and which vitamins, minerals or herbs are right for your body.  This is used for phone consultations with Jane Smolnik, ND, to make the most efficient use of our time together! 


We use a very sophisticated nutritional software program and analyze your test answers to identify which nutrients or supplements may be best for your body.  It’s the perfect way for you to know which nutritional supplements may be best for you!  Please answer ALL the questions. 


Once completed, you can click the 'Book Now' button below to set up a time for your Health Consultation.  You may choose the 1 Hour Health Consult by phone, or the 2 hr. Comprehensive Health Analysis in office, which includes a detailed Iridology assessment and Vital Scan HRV test.  


Jane will go over your results and put together a personalized recommended health program for you.  Your results and personalized recommendations will be emailed when we are finished.  NOTE: This is NOT to replace proper medical care.  You may be advised to see your medical doctor for serious conditions.


The way you answer each symptom question can give insight into nutritional deficiencies or needs you may have.

NOTE: If a question is asked more than once, please answer for every section.

You must complete ALL 3 pages!


Take your time and answer the questions as honestly as possible by rating each symptom with one of the following.

0- Never

1- Mild: occurs once a month or less

2- Moderate: occurs several times monthly

3- Severe: aware of it almost constantly

Be sure you hit 'Submit', it will take you to page 2

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