FREE HEALTH EVALUATION

PLEASE COMPLETE THE QUESTIONNAIRE FOR EVALUATION.

Name:
Sex:
male | female

Patient's Health Professional:

Birthday:
/ / (Month/Day/Year)

PART I

check any of the following medications you are taking:
Antacids Chemotherapy Hormones
Relaxants/Sleeping Pills Antibiotic/Antifungal Cortisone Anti-Inflammatories
Laxatives Antidepressants Recreational Drugs
Diuretics Lithium Specify:
Antidiabetic/Insulin Heart Medications Oral Contraceptives
Thyroid Aspirin/Tylenol High Blood Pressure
Radiation Ulcer Medications Other:
check, if you eat, drink, or use:
Alcohol Distilled Water Luncheon Meats
Non-Herbal Teas Candy Fluoridated/Chlorinated Water
Margarine Chew Tobacco Carbonated Beverages
At fast food restaurants regularly Refined Sugars Vitamins & Minerals
Cigarettes Fried Foods Milk Products
Coffee Refined (White) Flour Products Artificial Sweetners
Specify:
check if you:
Diet often Exercise less than 3 times weekly Are exposed to chemicals at work
Salt food without tasting Are under excessive stress Are exposed to cigarette smoke
DIRECTIONS: Please read each description and check the number which best describes the frequency of your symptoms within the past year. If you do not understand a symptom, choose '?'.
KEY: 0 = Never 1 = Mild
(Occurs once a month or less)
2 = Moderate
(Occurs several times monthly)
3 = Severe
(Aware of it almost constantly)

Part II - IMPORTANT

Dear Patient, Please list your five major health concerns in order of importance:
1.
2.
3.
4.
5.

Part III

Category I
Section A
1.Bad breath, halitosis (?:) 0:1:2:3:
2.Loss of taste for high protein foods (meat, etc.) (?:) 0:1:2:3:
3.Burning ("acid") or nervous stomach, eating relieves (?:) 0:1:2:3:
4.Gas shortly after eating (?:) 0:1:2:3:
5.Indigestion 1/2 to 1 hour after eating, may last 3-4 hours (?:) 0:1:2:3:
6.Difficulty digesting fruits or vegetables; undigested foods found in stools (?:) 0:1:2:3:
7.Acid or spicy foods upset stomach (?:) 0:1:2:3:
Section B
8.Lower bowel gas and or bloating several hours after eating (?:) 0:1:2:3:
9.Feet burn (?:) 0:1:2:3:
10."Whites" of eyes (sclera) yellow (?:) 0:1:2:3:
11.Dry skin, itchy feet and/or skin peels on feet (?:) 0:1:2:3:
12.Brown spots or bronzing of skin (?:) 0:1:2:3:
13.Bitter metallic taste in mouth (?:) 0:1:2:3:
14.Blurred vision (?:) 0:1:2:3:
15.Headache over eyes (?:) 0:1:2:3:
16.Feel nauseous, queasy or gag easily (?:) 0:1:2:3:
17.Color of stools light brown or yellow (?:) 0:1:2:3:
18.Greasy or high fat foods cause distress (?:) 0:1:2:3:
19.Pain between shoulder blades (?:) 0:1:2:3:
20.Dark circles under eyes (?:) 0:1:2:3:
21."Acid" breath (?:) 0:1:2:3:
22.History of gallbladder attacks or gallstones OR gallbladder removed (?:) yes:no:
23.Appetite reduced (?:) 0:1:2:3:
Section C
24.Coated tongue or "fuzzy" debris on tongue (?:) 0:1:2:3:
25.Pass large amounts of foul smelling gas (?:) 0:1:2:3:
26.Irritable bowel or mucous colitis (?:) 0:1:2:3:
27.Constipation, diarrhea alternating or stools alternate from soft to watery (?:) 0:1:2:3:
28.Bowel movements painful or difficult, constipation, and/or laxatives used (?:) 0:1:2:3:
29.Burning or itching anus (?:) 0:1:2:3:
Category II
30.Head congestion/"sinus fullness: (?:) 0:1:2:3:
31.Sneezing attacks (?:) 0:1:2:3:
32.Dreaming, nightmare-like bad dreams (?:) 0:1:2:3:
33.Milk products and/or wheat products cause distress (?:) 0:1:2:3:
34.Eyes and nose watery (?:) 0:1:2:3:
35.Eyes swollen and puffy (?:) 0:1:2:3:
36.Pulse speeds after meals and/or heart pounds after retiring (?:) 0:1:2:3:
Category III
37.Crave sweets or coffee in afternoon or mid-morning (?:) 0:1:2:3:
38.Hungry between meals or excessive appetite (?:) 0:1:2:3:
39.Overeating sweets upsets (?:) 0:1:2:3:
40.Eat when nervous (?:) 0:1:2:3:
41.Irritable before meals (?:) 0:1:2:3:
42.Get "shaky" or light-headed if meals delayed (?:) 0:1:2:3:
43.Fatigue, eating relieves (?:) 0:1:2:3:
44.Heart palpitates if meals missed or delayed (?:) 0:1:2:3:
45.Awaken a few hours after sleep, hard to get back to sleep (?:) 0:1:2:3:
Section B
46.Muscle soreness after moderate exercise (?:) 0:1:2:3:
47.Vulnerability to insect bites (especially fleas and mosquitoes) (?:) 0:1:2:3:
48.Loss of muscle tone or "heaviness" in arms or legs (?:) 0:1:2:3:
49.Enlarged heart and/or heart failure (?:) 0:1:2:3:
50.Worrier, feel insecure and/or highly emotional (?:) 0:1:2:3:
51.Pulse slow/below 65 or irregular pulse (?:) yes:no:
Category IV
Section A
52.Sex drive increased (?:) 0:1:2:3:
53."Splitting" type headaches (?:) 0:1:2:3:
54.Memory failing (?:) 0:1:2:3:
55.Tolerance for sugar reduced (?:) 0:1:2:3:
Section B
56.Sex drive reduced or absent (?:) 0:1:2:3:
57.Abnormal thirst (?:) 0:1:2:3:
58.Weight gain around hips or waist (?:) 0:1:2:3:
59.Tendency to ulcers or colitis (?:) 0:1:2:3:
60.Increased abilitly to eat sugar without symptoms (?:) 0:1:2:3:
61.Menstrual disorders (women) (?:) 0:1:2:3:
62.Lack of menstruation (young girls) (?:) 0:1:2:3:
Section C
63.Difficulty gaining weight, even if large appetite (?:) 0:1:2:3:
64.Heart palpitations (?:) 0:1:2:3:
65.Nervous, emotional, and/or can't work under pressure (?:) 0:1:2:3:
66.Insomnia (?:) 0:1:2:3:
67.Inward Trembling (?:) 0:1:2:3:
68.Night Sweats (?:) 0:1:2:3:
69.Fast pulse at rest (?:) 0:1:2:3:
70.Intolerant to high temperatures (?:) 0:1:2:3:
71.Easily flushed (?:) 0:1:2:3:
Section D
72.Difficulty losing weight (?:) 0:1:2:3:
73.Reduced initiative and/or mental sluggishness (?:) 0:1:2:3:
74.Easily fatigued, sleepy during the day (?:) 0:1:2:3:
75.Sensitive to cold, poor circulation (cold hands and feet) (?:) 0:1:2:3:
76.Dry or scaly skin (?:) 0:1:2:3:
77."Ringing" in ears/noises in head (?:) 0:1:2:3:
78.Hearing impaired (?:) 0:1:2:3:
79.Constipation (?:) 0:1:2:3:
80.Excessive falling hair and/or coarse hair (?:) 0:1:2:3:
81.Headaches when awaken/wear off during day (?:) 0:1:2:3:
Section E
82.Blood pressure increased (?:) 0:1:2:3:
83.Headaches (?:) 0:1:2:3:
84.Hot flashes (?:) 0:1:2:3:
85.Hair growth on face or body (Question to females) (?:) 0:1:2:3:
86.Masculine tendencies (Question to females) (?:) 0:1:2:3:
Section F
87.Blood pressure low (?:) 0:1:2:3:
88.Crave salt (?:) 0:1:2:3:
89.Chronic fatigue/get drowsy (?:) 0:1:2:3:
90.Afternoon yawning (?:) 0:1:2:3:
91.Weakness/dizziness (?:) 0:1:2:3:
92.Weakness after colds/slow recovery (?:) 0:1:2:3:
93.Circulation poor (?:) 0:1:2:3:
94.Muscular and nervous exhaustion (?:) 0:1:2:3:
95.Subject to colds, asthma, bronchitis (respiratory disorders) (?:) 0:1:2:3:
96.Allergies and/or hives (?:) 0:1:2:3:
97.Difficulty maintaining manipulative correction (?:) 0:1:2:3:
98.Arthritic tendencies (?:) 0:1:2:3:
99.Nails weak, ridged (?:) 0:1:2:3:
100.Perspire easily (?:) 0:1:2:3:
101.Slow starter in morning (?:) 0:1:2:3:
102.Afternoon headaches (?:) 0:1:2:3:
Category V
Section A
103.Frequent skin rashes and/or hives (?:) 0:1:2:3:
104.Muscle-leg-toe cramping at rest and/or while sleeping (?:) 0:1:2:3:
105.Fever easily raised/fevers common (?:) 0:1:2:3:
106.Crave Chocolate (?:) 0:1:2:3:
107.Feet have bad odor (?:) 0:1:2:3:
108.Hoarseness frequent (?:) 0:1:2:3:
109.Difficulty swallowing (?:) 0:1:2:3:
110.Joint stiffness after rising (?:) 0:1:2:3:
111.Vomiting frequent (?:) 0:1:2:3:
112.Tendency to anemia (?:) 0:1:2:3:
113."Whites" of eyes (sclera) blue (?:) 0:1:2:3:
114."Lump" in throat (?:) 0:1:2:3:
115.Dry mouth-eyes-nose (?:) 0:1:2:3:
116.White spots on finger nails (?:) 0:1:2:3:
117.Cuts heal slowly and/or scar easily (?:) 0:1:2:3:
118.Reduced or "lost" sense of taste and/or smell (?:) 0:1:2:3:
119.Susceptible to colds, fevers, and/or infections (?:) 0:1:2:3:
120.Strong light irritates eyes (?:) 0:1:2:3:
121.Noises in head or ringing in ears (?:) 0:1:2:3:
122.Burning sensations in mouth (?:) 0:1:2:3:
123.Numbness in hands and feet (extremities "go to sleep") (?:) 0:1:2:3:
124.Intolerant to monosodium glutamate (MSG) (?:) yes:no:
125.Cannot recall dreams (?:) 0:1:2:3:
126.Nose bleeds frequent (?:) 0:1:2:3:
127.Bruise easily, "black and blue" spots (?:) 0:1:2:3:
128.Muscle cramps, worse with exercise ("charley horses") (?:) 0:1:2:3:
Category VI
129.Aware of heavy and/or irregular breathing (?:) 0:1:2:3:
130.Discomfort in high altitudes (?:) 0:1:2:3:
131."Air hunger"/sigh frequently (?:) 0:1:2:3:
132.Swollen ankles/worse at night (?:) 0:1:2:3:
133.Shortness of breath with exertion (?:) 0:1:2:3:
134.Dull pain in chest and/or pain radiating into left arm, worse on exertion (?:) 0:1:2:3:
Category VII
Female Only
135.Premenstrual tension (?:) 0:1:2:3:
136.Painful menses (cramping,etc.) (?:) 0:1:2:3:
137.Menstruation excessive or prolonged (?:) 0:1:2:3:
138.Painful/tender breasts (?:) 0:1:2:3:
139.Menstruate too frequently (?:) 0:1:2:3:
140.Acne, worse at menses (?:) 0:1:2:3:
141.Depressed feelings before menstruation (?:) 0:1:2:3:
142.Vaginal discharge (?:) 0:1:2:3:
143.Menses scanty or missed (?:) 0:1:2:3:
144.Hysterectomy/ovaries removed (?:) yes:no:
145.Menopausal hot flashes (?:) 0:1:2:3:
146.Depression (?:) 0:1:2:3:
Category VIII
Male Only
147.Prostate trouble (?:) 0:1:2:3:
148.Urination difficult or dribbling (?:) 0:1:2:3:
149.Night urination frequent (?:) 0:1:2:3:
150.Pain on inside of legs or heels (?:) 0:1:2:3:
151.Feeling of incomplete bowel evacuation (?:) 0:1:2:3:
152.Leg nervousness at night (?:) 0:1:2:3:
153.Tire easily/avoid activity (?:) 0:1:2:3:
154.Reduced sex drive (?:) 0:1:2:3:
155.Depression (?:) 0:1:2:3:
156.Migrating aches and pains (?:) 0:1:2:3:

the result of the evaluation will be send to you as soon as possible
to your email address:

please add your phone number for queries:

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