Folic Acid Mini-Test Name* First Last Email* Select all that apply: Delayed wound healing Lack of appetite Heartburn and/or indigestion Inflammation and/or soreness of the tongue Cracks at the corners of the mouth Lips which are constantly chapped Memory loss Growth impairment Dry and/or brittle hair Slow growing nails and/or hair Mouth sores, that is canker sores Receding and/or bleeding gums None of these apply Do you have hangnails?* Moderately Severely No Do you smoke cigarettes heavily, that is one-third pack or more per day, or have you smoked heavily in the past for over five years?* Yes No Do you consume alcoholic beverages?* One or two drinks daily Three to five drinks daily Six or more drinks daily No Do you consume refined sugar obviously which is often hidden in food?* Moderately Severely Extremely No Do you have a history of abnormal pap smears, cervical dysplasia, and/or cervical cancer?* Yes No Do you have gout?* Yes No Do you have celiac disease and/or wheat allergy?* Yes No Do you avoid eating dark leafy green vegetables?* Yes No Do you take birth control pills currently?* Yes No Have you taken birth control pills in the past for five or more years?* Yes No Do you take antibiotics?* Yes, several doses per year Yes, several doses per month or week No Do you take Dilantin?* Yes No Do you take Tagamet, Pepsid, Nexium, or Zantac on a daily or weekly basis?* Yes No Do you take aspirin on a daily or weekly basis?* Yes No Are you on the drug Methotrexate and/or are you under-going chemotherapy?* Yes No
