Submit Your Information

Phone Order Process: After you fill out the form below, we will give you the toll free number (available 24 hours a day) to submit your credit card info.

Please answer the following questions, this information will be sent directly to Dr. Janet Starr Hull. Dr. Hull will use the following information to interpret your report and provide specific nutritional recommendations. Please keep in mind the following information will be kept in the strictest confidentiality and will only be accessible by Dr. Janet Starr Hull as stated in our Disclaimer.

Patient Information (For Our Records Only):
Name:*
Zip Code:*
Email:*
Country:*
Address:*
Phone Number:*
City:*
Birth Date:*
State:*
Sex:*


Hair Elements:
Natural Hair Color:*
Past 60 days have you used:
 Perm
Dye
Bleach
Shampoo Used:*
Type of hair provided for test:*
Date of hair sample*:


Aspartame Information:
Do you currently consume aspartame?*
Did you ever consume aspartame?*
How long have you been using aspartame or how long did you consume aspartame?
Did your health symptoms begin after you started using aspartame (think back)?
Do you or did you ever use Equal (the blue packet)?*
Please list the diet products you use / used regularly:


Medical / Health Information:
Do you have allergies?
 Seasonal Molds Food
Do you have stomach problems?
 Indigestion Constipation Diarrhea
Do you have diabetes?*
   
How many hours do you sleep on average?
How do you feel when you wake up?
 Rested Tired Depressed Sore
Please select all that apply:
 Alcoholism (Past or Present)
Heart Disease
Headaches
Skin Problems
Depression
Muscle Aches
   
Do you currently take medications?*
Please list your medications you use or used regularly:
Have you ever had surgery?*
Please explain your surgery:


Would you like to:
Please select all
that apply:

Have more energy
Be stronger
Be more muscular
Be free of pain
Get rid of allergies
Have less colds or flu
Improve memory
Sleep longer and better
Lose weight
Feel more motivated

Be more emotionally stable
Be less dependent on over-the-counter medications (i.e. aspirin)
Reduce risk of inherited disease
Other:


Other Information:

Other Information or additional comments for Dr Hull including genetic history of concern:
How did you hear about Dr. Hull's hair analysis program?*
Other:


Questions about the information above? Please visit our Hair Analysis FAQ page.
Dr. Janet Starr Hull Photo


Step One: Submit Your Info
Step Two: Hair Instructions
Step Three: Payment