Health Assessment Form
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1. Default Section

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Balancing Body Chemistry Health Assessment Form

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1. Please provide the following information:

Please provide the following information: Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

2. Who referred you to this site?

Who referred you to this site?

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3. Date of Birth

Date of Birth

4. Mark any of the following medications you are taking:

Mark any of the following medications you are taking: Antacids

Antibiotic/Antifungal

Antidepressants

Antidiabetic/Insulin

Asprin/Tylenol

Chemotherapy

Cortisone Anti-Inflammatories

Diuretics

Heart Medications

High Blood Pressure

Hormones

Laxatives

Lithium

Oral Contraceptives

Radiation

Relaxants/Sleeping Pills

Recreational Drugs

Thyroid

Ulcer Medications

5. Mark if you eat, drink or use:

Mark if you eat, drink or use: Alcohol

Candy

Carbonated Beverages

Cigarettes

Coffee

Distilled Water

Fluordinated/Chlorinated Water

At fast food restaurants regularly

Fried Foods

Refined (White) Flour Products

Luncheon Meats

Margarine

Refined Sugars

Milk Products

Artificial Sweeteners

Non-Herbal Teas

Chew Tobacco

Vitamins & Minerals

6. Mark if you:

Mark if you: Diet often

Salt food without tasting

Exercise less than 3 times weekly

Are under excessive stress

Are exposed to chemicals at work

Are exposed to cigarette smoke

7. Please list your five major health concerns in order of importance.

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

8. Please list medication and supplements you currently take.

Please list medication and supplements you currently take. 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Please read each description and check the number which best describes the frequency o fyour symptoms within the past year.

0=Never
1=Mild (Occurs once a month or less)
2=Moderate(Occurs several times monthly)
3=Severe (Aware of it almost constantly)

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9. Category I
Section A:

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10. Category II

	0-Never	1-Mild	2-Moderate	3-Severe
30. Head congestion/"sinus fullness"	*Category II 30. Head congestion/"sinus fullness" 0-Never	30. Head congestion/"sinus fullness" 1-Mild	30. Head congestion/"sinus fullness" 2-Moderate	30. Head congestion/"sinus fullness" 3-Severe
31. Sneezing attacks	31. Sneezing attacks 0-Never	31. Sneezing attacks 1-Mild	31. Sneezing attacks 2-Moderate	31. Sneezing attacks 3-Severe
32. Dreaming, nightmare-like bad dreams	32. Dreaming, nightmare-like bad dreams 0-Never	32. Dreaming, nightmare-like bad dreams 1-Mild	32. Dreaming, nightmare-like bad dreams 2-Moderate	32. Dreaming, nightmare-like bad dreams 3-Severe
33. Milk products and/or wheat products cause distress	33. Milk products and/or wheat products cause distress 0-Never	33. Milk products and/or wheat products cause distress 1-Mild	33. Milk products and/or wheat products cause distress 2-Moderate	33. Milk products and/or wheat products cause distress 3-Severe
34. Eyes and nose watery	34. Eyes and nose watery 0-Never	34. Eyes and nose watery 1-Mild	34. Eyes and nose watery 2-Moderate	34. Eyes and nose watery 3-Severe
35. Eyes swollen and puffy	35. Eyes swollen and puffy 0-Never	35. Eyes swollen and puffy 1-Mild	35. Eyes swollen and puffy 2-Moderate	35. Eyes swollen and puffy 3-Severe
36. Pulse speeds after meals and/or heart pounds after retiring	36. Pulse speeds after meals and/or heart pounds after retiring 0-Never	36. Pulse speeds after meals and/or heart pounds after retiring 1-Mild	36. Pulse speeds after meals and/or heart pounds after retiring 2-Moderate	36. Pulse speeds after meals and/or heart pounds after retiring 3-Severe

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11. Category III
Section A

	0-Never	1-Mild	2-Moderate	3-Severe
37. Crave Sweets or coffee in afternoon or mid-morning	*Category III Section A 37. Crave Sweets or coffee in afternoon or mid-morning 0-Never	37. Crave Sweets or coffee in afternoon or mid-morning 1-Mild	37. Crave Sweets or coffee in afternoon or mid-morning 2-Moderate	37. Crave Sweets or coffee in afternoon or mid-morning 3-Severe
38. Hungry between meals or excessive appetite	38. Hungry between meals or excessive appetite 0-Never	38. Hungry between meals or excessive appetite 1-Mild	38. Hungry between meals or excessive appetite 2-Moderate	38. Hungry between meals or excessive appetite 3-Severe
39. Overeating sweets upsets	39. Overeating sweets upsets 0-Never	39. Overeating sweets upsets 1-Mild	39. Overeating sweets upsets 2-Moderate	39. Overeating sweets upsets 3-Severe
40. Eat when nervous	40. Eat when nervous 0-Never	40. Eat when nervous 1-Mild	40. Eat when nervous 2-Moderate	40. Eat when nervous 3-Severe
41. Irritable before meals	41. Irritable before meals 0-Never	41. Irritable before meals 1-Mild	41. Irritable before meals 2-Moderate	41. Irritable before meals 3-Severe
42. Get "shaky" or light-headed if meals delay	42. Get "shaky" or light-headed if meals delay 0-Never	42. Get "shaky" or light-headed if meals delay 1-Mild	42. Get "shaky" or light-headed if meals delay 2-Moderate	42. Get "shaky" or light-headed if meals delay 3-Severe
43. Fatigue, eating relieves	43. Fatigue, eating relieves 0-Never	43. Fatigue, eating relieves 1-Mild	43. Fatigue, eating relieves 2-Moderate	43. Fatigue, eating relieves 3-Severe
44. Heart palpitates if meals missed or delayed	44. Heart palpitates if meals missed or delayed 0-Never	44. Heart palpitates if meals missed or delayed 1-Mild	44. Heart palpitates if meals missed or delayed 2-Moderate	44. Heart palpitates if meals missed or delayed 3-Severe
45. Awaken a few hours after sleep, hard to get back to sleep	45. Awaken a few hours after sleep, hard to get back to sleep 0-Never	45. Awaken a few hours after sleep, hard to get back to sleep 1-Mild	45. Awaken a few hours after sleep, hard to get back to sleep 2-Moderate	45. Awaken a few hours after sleep, hard to get back to sleep 3-Severe

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12. Section B

	0-Never	1-Mild	2-Moderate	3-Severe
46. Muscle soreness after moderate exercise	*Section B 46. Muscle soreness after moderate exercise 0-Never	46. Muscle soreness after moderate exercise 1-Mild	46. Muscle soreness after moderate exercise 2-Moderate	46. Muscle soreness after moderate exercise 3-Severe
47. Vulnerability to insect bites (especially fleas and mosquitoes)	47. Vulnerability to insect bites (especially fleas and mosquitoes) 0-Never	47. Vulnerability to insect bites (especially fleas and mosquitoes) 1-Mild	47. Vulnerability to insect bites (especially fleas and mosquitoes) 2-Moderate	47. Vulnerability to insect bites (especially fleas and mosquitoes) 3-Severe
48. Loss of muscle tone or "heaviness" in arms or legs	48. Loss of muscle tone or "heaviness" in arms or legs 0-Never	48. Loss of muscle tone or "heaviness" in arms or legs 1-Mild	48. Loss of muscle tone or "heaviness" in arms or legs 2-Moderate	48. Loss of muscle tone or "heaviness" in arms or legs 3-Severe
49. Enlarged Heart and/or heart failure	49. Enlarged Heart and/or heart failure 0-Never	49. Enlarged Heart and/or heart failure 1-Mild	49. Enlarged Heart and/or heart failure 2-Moderate	49. Enlarged Heart and/or heart failure 3-Severe
50. Worrier, feel insecure and/or highly emotional	50. Worrier, feel insecure and/or highly emotional 0-Never	50. Worrier, feel insecure and/or highly emotional 1-Mild	50. Worrier, feel insecure and/or highly emotional 2-Moderate	50. Worrier, feel insecure and/or highly emotional 3-Severe
51. Pulse slow/below 65 or irregular pulse	51. Pulse slow/below 65 or irregular pulse 0-Never	51. Pulse slow/below 65 or irregular pulse 1-Mild	51. Pulse slow/below 65 or irregular pulse 2-Moderate	51. Pulse slow/below 65 or irregular pulse 3-Severe

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13. Category IV
Section A:

	0-Never	1-Mild	2-Moderate	3-Severe
52. Sex drive increased	*Category IV Section A: 52. Sex drive increased 0-Never	52. Sex drive increased 1-Mild	52. Sex drive increased 2-Moderate	52. Sex drive increased 3-Severe
53. "Splitting" type headaches	53. "Splitting" type headaches 0-Never	53. "Splitting" type headaches 1-Mild	53. "Splitting" type headaches 2-Moderate	53. "Splitting" type headaches 3-Severe
54. Memory failing	54. Memory failing 0-Never	54. Memory failing 1-Mild	54. Memory failing 2-Moderate	54. Memory failing 3-Severe
55. Tolerance for sugar reduced	55. Tolerance for sugar reduced 0-Never	55. Tolerance for sugar reduced 1-Mild	55. Tolerance for sugar reduced 2-Moderate	55. Tolerance for sugar reduced 3-Severe

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14. Section B

	0-Never	1-Mild	2-Moderate	3-Severe
56. Sex drive reduce or absent	*Section B 56. Sex drive reduce or absent 0-Never	56. Sex drive reduce or absent 1-Mild	56. Sex drive reduce or absent 2-Moderate	56. Sex drive reduce or absent 3-Severe
57. Abnormal thirst	57. Abnormal thirst 0-Never	57. Abnormal thirst 1-Mild	57. Abnormal thirst 2-Moderate	57. Abnormal thirst 3-Severe
58. Weight gain around hips or waist	58. Weight gain around hips or waist 0-Never	58. Weight gain around hips or waist 1-Mild	58. Weight gain around hips or waist 2-Moderate	58. Weight gain around hips or waist 3-Severe
59. Tendency to ulcers or colitis	59. Tendency to ulcers or colitis 0-Never	59. Tendency to ulcers or colitis 1-Mild	59. Tendency to ulcers or colitis 2-Moderate	59. Tendency to ulcers or colitis 3-Severe
60. Increased ability to eat sugar without symptoms	60. Increased ability to eat sugar without symptoms 0-Never	60. Increased ability to eat sugar without symptoms 1-Mild	60. Increased ability to eat sugar without symptoms 2-Moderate	60. Increased ability to eat sugar without symptoms 3-Severe
61. Menstrual disorders (women)	61. Menstrual disorders (women) 0-Never	61. Menstrual disorders (women) 1-Mild	61. Menstrual disorders (women) 2-Moderate	61. Menstrual disorders (women) 3-Severe
62. Lack of menstruation (young girls)	62. Lack of menstruation (young girls) 0-Never	62. Lack of menstruation (young girls) 1-Mild	62. Lack of menstruation (young girls) 2-Moderate	62. Lack of menstruation (young girls) 3-Severe

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15. Section C

	0-Never	1-Mild	2-Moderate	3-Severe
63. Difficulty gaining weight, even if large appetite	*Section C 63. Difficulty gaining weight, even if large appetite 0-Never	63. Difficulty gaining weight, even if large appetite 1-Mild	63. Difficulty gaining weight, even if large appetite 2-Moderate	63. Difficulty gaining weight, even if large appetite 3-Severe
64. Heart palpitations	64. Heart palpitations 0-Never	64. Heart palpitations 1-Mild	64. Heart palpitations 2-Moderate	64. Heart palpitations 3-Severe
65. Nervous, emotional, and/or can't work under pressure	65. Nervous, emotional, and/or can't work under pressure 0-Never	65. Nervous, emotional, and/or can't work under pressure 1-Mild	65. Nervous, emotional, and/or can't work under pressure 2-Moderate	65. Nervous, emotional, and/or can't work under pressure 3-Severe
66. Insomnia	66. Insomnia 0-Never	66. Insomnia 1-Mild	66. Insomnia 2-Moderate	66. Insomnia 3-Severe
67. Inward Trembling	67. Inward Trembling 0-Never	67. Inward Trembling 1-Mild	67. Inward Trembling 2-Moderate	67. Inward Trembling 3-Severe
68. Night Sweats	68. Night Sweats 0-Never	68. Night Sweats 1-Mild	68. Night Sweats 2-Moderate	68. Night Sweats 3-Severe
69. Fast pulse at rest	69. Fast pulse at rest 0-Never	69. Fast pulse at rest 1-Mild	69. Fast pulse at rest 2-Moderate	69. Fast pulse at rest 3-Severe
70. Intolerant to high temperatures	70. Intolerant to high temperatures 0-Never	70. Intolerant to high temperatures 1-Mild	70. Intolerant to high temperatures 2-Moderate	70. Intolerant to high temperatures 3-Severe
71. Easily flushed	71. Easily flushed 0-Never	71. Easily flushed 1-Mild	71. Easily flushed 2-Moderate	71. Easily flushed 3-Severe

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16. Section D

	0-Never	1-Mild	2-Moderate	3-Severe
72. Difficulty losing weight	*Section D 72. Difficulty losing weight 0-Never	72. Difficulty losing weight 1-Mild	72. Difficulty losing weight 2-Moderate	72. Difficulty losing weight 3-Severe
73. Reduced initiative and/or mental sluggishness	73. Reduced initiative and/or mental sluggishness 0-Never	73. Reduced initiative and/or mental sluggishness 1-Mild	73. Reduced initiative and/or mental sluggishness 2-Moderate	73. Reduced initiative and/or mental sluggishness 3-Severe
74. Easily fatigued, sleepy during the day	74. Easily fatigued, sleepy during the day 0-Never	74. Easily fatigued, sleepy during the day 1-Mild	74. Easily fatigued, sleepy during the day 2-Moderate	74. Easily fatigued, sleepy during the day 3-Severe
75. Sensitive to cold, poor circulation (cold hands and feet)	75. Sensitive to cold, poor circulation (cold hands and feet) 0-Never	75. Sensitive to cold, poor circulation (cold hands and feet) 1-Mild	75. Sensitive to cold, poor circulation (cold hands and feet) 2-Moderate	75. Sensitive to cold, poor circulation (cold hands and feet) 3-Severe
76. Dry or scaly skin	76. Dry or scaly skin 0-Never	76. Dry or scaly skin 1-Mild	76. Dry or scaly skin 2-Moderate	76. Dry or scaly skin 3-Severe
77. "Ringing" in ears/noises in head	77. "Ringing" in ears/noises in head 0-Never	77. "Ringing" in ears/noises in head 1-Mild	77. "Ringing" in ears/noises in head 2-Moderate	77. "Ringing" in ears/noises in head 3-Severe
78. Hearing impaired	78. Hearing impaired 0-Never	78. Hearing impaired 1-Mild	78. Hearing impaired 2-Moderate	78. Hearing impaired 3-Severe
79. Constipation	79. Constipation 0-Never	79. Constipation 1-Mild	79. Constipation 2-Moderate	79. Constipation 3-Severe
80. Excessive falling hair and/or coarse hair	80. Excessive falling hair and/or coarse hair 0-Never	80. Excessive falling hair and/or coarse hair 1-Mild	80. Excessive falling hair and/or coarse hair 2-Moderate	80. Excessive falling hair and/or coarse hair 3-Severe
81. Headaches when awaken/wear off during day	81. Headaches when awaken/wear off during day 0-Never	81. Headaches when awaken/wear off during day 1-Mild	81. Headaches when awaken/wear off during day 2-Moderate	81. Headaches when awaken/wear off during day 3-Severe

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17. Section E

	0-Never	1-Mild	2-Moderate	3-Severe
82. Blood pressure increased	*Section E 82. Blood pressure increased 0-Never	82. Blood pressure increased 1-Mild	82. Blood pressure increased 2-Moderate	82. Blood pressure increased 3-Severe
83. Headaches	83. Headaches 0-Never	83. Headaches 1-Mild	83. Headaches 2-Moderate	83. Headaches 3-Severe
84. Hot flashes	84. Hot flashes 0-Never	84. Hot flashes 1-Mild	84. Hot flashes 2-Moderate	84. Hot flashes 3-Severe
85. Hair growth on face or body (Question to females)	85. Hair growth on face or body (Question to females) 0-Never	85. Hair growth on face or body (Question to females) 1-Mild	85. Hair growth on face or body (Question to females) 2-Moderate	85. Hair growth on face or body (Question to females) 3-Severe
86. Masculine tendencies (Question to females)	86. Masculine tendencies (Question to females) 0-Never	86. Masculine tendencies (Question to females) 1-Mild	86. Masculine tendencies (Question to females) 2-Moderate	86. Masculine tendencies (Question to females) 3-Severe

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18. Section F

	0-Never	1-Mild	2-Moderate	3-Severe
87. Blood pressure low	*Section F 87. Blood pressure low 0-Never	87. Blood pressure low 1-Mild	87. Blood pressure low 2-Moderate	87. Blood pressure low 3-Severe
88. Crave salt	88. Crave salt 0-Never	88. Crave salt 1-Mild	88. Crave salt 2-Moderate	88. Crave salt 3-Severe
89. Chronic fatigue/get drowsy	89. Chronic fatigue/get drowsy 0-Never	89. Chronic fatigue/get drowsy 1-Mild	89. Chronic fatigue/get drowsy 2-Moderate	89. Chronic fatigue/get drowsy 3-Severe
90. Afternoon yawning	90. Afternoon yawning 0-Never	90. Afternoon yawning 1-Mild	90. Afternoon yawning 2-Moderate	90. Afternoon yawning 3-Severe
91. Weakness/dizziness	91. Weakness/dizziness 0-Never	91. Weakness/dizziness 1-Mild	91. Weakness/dizziness 2-Moderate	91. Weakness/dizziness 3-Severe
92. Weakness after colds/slow recovery	92. Weakness after colds/slow recovery 0-Never	92. Weakness after colds/slow recovery 1-Mild	92. Weakness after colds/slow recovery 2-Moderate	92. Weakness after colds/slow recovery 3-Severe
93. Circulation poor	93. Circulation poor 0-Never	93. Circulation poor 1-Mild	93. Circulation poor 2-Moderate	93. Circulation poor 3-Severe
94. Muscular and nervous exhaustion	94. Muscular and nervous exhaustion 0-Never	94. Muscular and nervous exhaustion 1-Mild	94. Muscular and nervous exhaustion 2-Moderate	94. Muscular and nervous exhaustion 3-Severe
95. Subject ot colds, asthma, bronchitis (respiratory disorders)	95. Subject ot colds, asthma, bronchitis (respiratory disorders) 0-Never	95. Subject ot colds, asthma, bronchitis (respiratory disorders) 1-Mild	95. Subject ot colds, asthma, bronchitis (respiratory disorders) 2-Moderate	95. Subject ot colds, asthma, bronchitis (respiratory disorders) 3-Severe
96. Allergies and/or hives	96. Allergies and/or hives 0-Never	96. Allergies and/or hives 1-Mild	96. Allergies and/or hives 2-Moderate	96. Allergies and/or hives 3-Severe
97. Difficulty maintaining manipulative correction	97. Difficulty maintaining manipulative correction 0-Never	97. Difficulty maintaining manipulative correction 1-Mild	97. Difficulty maintaining manipulative correction 2-Moderate	97. Difficulty maintaining manipulative correction 3-Severe
98. Arthritic tendencies	98. Arthritic tendencies 0-Never	98. Arthritic tendencies 1-Mild	98. Arthritic tendencies 2-Moderate	98. Arthritic tendencies 3-Severe
99. Nails weak, ridged	99. Nails weak, ridged 0-Never	99. Nails weak, ridged 1-Mild	99. Nails weak, ridged 2-Moderate	99. Nails weak, ridged 3-Severe
100. Perspire easily	100. Perspire easily 0-Never	100. Perspire easily 1-Mild	100. Perspire easily 2-Moderate	100. Perspire easily 3-Severe
101. Slow starter in morning	101. Slow starter in morning 0-Never	101. Slow starter in morning 1-Mild	101. Slow starter in morning 2-Moderate	101. Slow starter in morning 3-Severe
102. Afternoon headaches	102. Afternoon headaches 0-Never	102. Afternoon headaches 1-Mild	102. Afternoon headaches 2-Moderate	102. Afternoon headaches 3-Severe

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19. Category V
Section A:

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20. Category VI

	0-Never	1-Mild	2-Moderate	3-Severe
129. Aware of heavy and/or irregular breathing	*Category VI 129. Aware of heavy and/or irregular breathing 0-Never	129. Aware of heavy and/or irregular breathing 1-Mild	129. Aware of heavy and/or irregular breathing 2-Moderate	129. Aware of heavy and/or irregular breathing 3-Severe
130. Discomfort in high altitudes	130. Discomfort in high altitudes 0-Never	130. Discomfort in high altitudes 1-Mild	130. Discomfort in high altitudes 2-Moderate	130. Discomfort in high altitudes 3-Severe
131. "Air hunger"/sigh frequently	131. "Air hunger"/sigh frequently 0-Never	131. "Air hunger"/sigh frequently 1-Mild	131. "Air hunger"/sigh frequently 2-Moderate	131. "Air hunger"/sigh frequently 3-Severe
132. Swollen ankles/worse at night	132. Swollen ankles/worse at night 0-Never	132. Swollen ankles/worse at night 1-Mild	132. Swollen ankles/worse at night 2-Moderate	132. Swollen ankles/worse at night 3-Severe
133. Shortness of breath with exertion	133. Shortness of breath with exertion 0-Never	133. Shortness of breath with exertion 1-Mild	133. Shortness of breath with exertion 2-Moderate	133. Shortness of breath with exertion 3-Severe
134. Dull pain in chest and/or pain radiating into left arm, worse on exertion	134. Dull pain in chest and/or pain radiating into left arm, worse on exertion 0-Never	134. Dull pain in chest and/or pain radiating into left arm, worse on exertion 1-Mild	134. Dull pain in chest and/or pain radiating into left arm, worse on exertion 2-Moderate	134. Dull pain in chest and/or pain radiating into left arm, worse on exertion 3-Severe

21. Category VII
Female Only

	0-Never	1-Mild	2-Moderate	3-Severe
135. Premenstrual tension	*Category VII Female Only 135. Premenstrual tension 0-Never	135. Premenstrual tension 1-Mild	135. Premenstrual tension 2-Moderate	135. Premenstrual tension 3-Severe
136. Painful menses (cramping, etc)	136. Painful menses (cramping, etc) 0-Never	136. Painful menses (cramping, etc) 1-Mild	136. Painful menses (cramping, etc) 2-Moderate	136. Painful menses (cramping, etc) 3-Severe
137. Menstruation excessive or prolonged	137. Menstruation excessive or prolonged 0-Never	137. Menstruation excessive or prolonged 1-Mild	137. Menstruation excessive or prolonged 2-Moderate	137. Menstruation excessive or prolonged 3-Severe
138. Painful/tender breasts	138. Painful/tender breasts 0-Never	138. Painful/tender breasts 1-Mild	138. Painful/tender breasts 2-Moderate	138. Painful/tender breasts 3-Severe
139. Menstruate too frequently	139. Menstruate too frequently 0-Never	139. Menstruate too frequently 1-Mild	139. Menstruate too frequently 2-Moderate	139. Menstruate too frequently 3-Severe
140. Acne, worse at menses	140. Acne, worse at menses 0-Never	140. Acne, worse at menses 1-Mild	140. Acne, worse at menses 2-Moderate	140. Acne, worse at menses 3-Severe
141. Depressed feelings before menstruation	141. Depressed feelings before menstruation 0-Never	141. Depressed feelings before menstruation 1-Mild	141. Depressed feelings before menstruation 2-Moderate	141. Depressed feelings before menstruation 3-Severe
142. Vaginal discharge	142. Vaginal discharge 0-Never	142. Vaginal discharge 1-Mild	142. Vaginal discharge 2-Moderate	142. Vaginal discharge 3-Severe
143. Menses scanty or missed	143. Menses scanty or missed 0-Never	143. Menses scanty or missed 1-Mild	143. Menses scanty or missed 2-Moderate	143. Menses scanty or missed 3-Severe
144. Hysterectomy/ovaries removed	144. Hysterectomy/ovaries removed 0-Never	144. Hysterectomy/ovaries removed 1-Mild	144. Hysterectomy/ovaries removed 2-Moderate	144. Hysterectomy/ovaries removed 3-Severe
145. Menopausal hot flashes	145. Menopausal hot flashes 0-Never	145. Menopausal hot flashes 1-Mild	145. Menopausal hot flashes 2-Moderate	145. Menopausal hot flashes 3-Severe
146. Depression	146. Depression 0-Never	146. Depression 1-Mild	146. Depression 2-Moderate	146. Depression 3-Severe

22. Category VIII
Male Only

	0-Never	1-Mild	2-Moderate	3-Severe
147. Prostate trouble	*Category VIII Male Only 147. Prostate trouble 0-Never	147. Prostate trouble 1-Mild	147. Prostate trouble 2-Moderate	147. Prostate trouble 3-Severe
148. Urination difficult or dribbling	148. Urination difficult or dribbling 0-Never	148. Urination difficult or dribbling 1-Mild	148. Urination difficult or dribbling 2-Moderate	148. Urination difficult or dribbling 3-Severe
149. Night urination frequent	149. Night urination frequent 0-Never	149. Night urination frequent 1-Mild	149. Night urination frequent 2-Moderate	149. Night urination frequent 3-Severe
150. Pain on inside of legs or heels	150. Pain on inside of legs or heels 0-Never	150. Pain on inside of legs or heels 1-Mild	150. Pain on inside of legs or heels 2-Moderate	150. Pain on inside of legs or heels 3-Severe
151. Feeling of incomplete bowel evacuation	151. Feeling of incomplete bowel evacuation 0-Never	151. Feeling of incomplete bowel evacuation 1-Mild	151. Feeling of incomplete bowel evacuation 2-Moderate	151. Feeling of incomplete bowel evacuation 3-Severe
152. Leg nervousness at night	152. Leg nervousness at night 0-Never	152. Leg nervousness at night 1-Mild	152. Leg nervousness at night 2-Moderate	152. Leg nervousness at night 3-Severe
153. Tire easily/avoid activity	153. Tire easily/avoid activity 0-Never	153. Tire easily/avoid activity 1-Mild	153. Tire easily/avoid activity 2-Moderate	153. Tire easily/avoid activity 3-Severe
154. Reduced sex drive	154. Reduced sex drive 0-Never	154. Reduced sex drive 1-Mild	154. Reduced sex drive 2-Moderate	154. Reduced sex drive 3-Severe
155. Depression	155. Depression 0-Never	155. Depression 1-Mild	155. Depression 2-Moderate	155. Depression 3-Severe
156. Migrating aches and pains	156. Migrating aches and pains 0-Never	156. Migrating aches and pains 1-Mild	156. Migrating aches and pains 2-Moderate	156. Migrating aches and pains 3-Severe

	0-Never	1-Mild	2-Moderate	3-Severe
1. Bad breath, halitosis	*Category I Section A: 1. Bad breath, halitosis 0-Never	1. Bad breath, halitosis 1-Mild	1. Bad breath, halitosis 2-Moderate	1. Bad breath, halitosis 3-Severe
2. Loss of taste for high protein foods (meat, etc.)	2. Loss of taste for high protein foods (meat, etc.) 0-Never	2. Loss of taste for high protein foods (meat, etc.) 1-Mild	2. Loss of taste for high protein foods (meat, etc.) 2-Moderate	2. Loss of taste for high protein foods (meat, etc.) 3-Severe
3. Burning (acid) or nervous stomach, eating relieves	3. Burning (acid) or nervous stomach, eating relieves 0-Never	3. Burning (acid) or nervous stomach, eating relieves 1-Mild	3. Burning (acid) or nervous stomach, eating relieves 2-Moderate	3. Burning (acid) or nervous stomach, eating relieves 3-Severe
4. Gas shortly after eating	4. Gas shortly after eating 0-Never	4. Gas shortly after eating 1-Mild	4. Gas shortly after eating 2-Moderate	4. Gas shortly after eating 3-Severe
5. Indigestion 1/2 to 1 hour after eating, may last 3-4 hours	5. Indigestion 1/2 to 1 hour after eating, may last 3-4 hours 0-Never	5. Indigestion 1/2 to 1 hour after eating, may last 3-4 hours 1-Mild	5. Indigestion 1/2 to 1 hour after eating, may last 3-4 hours 2-Moderate	5. Indigestion 1/2 to 1 hour after eating, may last 3-4 hours 3-Severe
6. Difficutly digesting fruits or vegetables; undisgested foods found in stools	6. Difficutly digesting fruits or vegetables; undisgested foods found in stools 0-Never	6. Difficutly digesting fruits or vegetables; undisgested foods found in stools 1-Mild	6. Difficutly digesting fruits or vegetables; undisgested foods found in stools 2-Moderate	6. Difficutly digesting fruits or vegetables; undisgested foods found in stools 3-Severe
7. Acid or spicy foods upset stomach	7. Acid or spicy foods upset stomach 0-Never	7. Acid or spicy foods upset stomach 1-Mild	7. Acid or spicy foods upset stomach 2-Moderate	7. Acid or spicy foods upset stomach 3-Severe
Section B:	Section B: 0-Never	Section B: 1-Mild	Section B: 2-Moderate	Section B: 3-Severe
8. Lower bowel gas and or bloating several hours after eating	8. Lower bowel gas and or bloating several hours after eating 0-Never	8. Lower bowel gas and or bloating several hours after eating 1-Mild	8. Lower bowel gas and or bloating several hours after eating 2-Moderate	8. Lower bowel gas and or bloating several hours after eating 3-Severe
9. Feet burn	9. Feet burn 0-Never	9. Feet burn 1-Mild	9. Feet burn 2-Moderate	9. Feet burn 3-Severe
10. "Whites" of eyes (sclera) yellow	10. "Whites" of eyes (sclera) yellow 0-Never	10. "Whites" of eyes (sclera) yellow 1-Mild	10. "Whites" of eyes (sclera) yellow 2-Moderate	10. "Whites" of eyes (sclera) yellow 3-Severe
11. Dry skin, itchy feet and/or skin peels on feet	11. Dry skin, itchy feet and/or skin peels on feet 0-Never	11. Dry skin, itchy feet and/or skin peels on feet 1-Mild	11. Dry skin, itchy feet and/or skin peels on feet 2-Moderate	11. Dry skin, itchy feet and/or skin peels on feet 3-Severe
12. Brown spots or bronzing of skin	12. Brown spots or bronzing of skin 0-Never	12. Brown spots or bronzing of skin 1-Mild	12. Brown spots or bronzing of skin 2-Moderate	12. Brown spots or bronzing of skin 3-Severe
13. Bitter metallic taste in mouth	13. Bitter metallic taste in mouth 0-Never	13. Bitter metallic taste in mouth 1-Mild	13. Bitter metallic taste in mouth 2-Moderate	13. Bitter metallic taste in mouth 3-Severe
14. Blurred vision	14. Blurred vision 0-Never	14. Blurred vision 1-Mild	14. Blurred vision 2-Moderate	14. Blurred vision 3-Severe
15. Headache over eyes	15. Headache over eyes 0-Never	15. Headache over eyes 1-Mild	15. Headache over eyes 2-Moderate	15. Headache over eyes 3-Severe
16. Feel nauseous, queasy or gag easily	16. Feel nauseous, queasy or gag easily 0-Never	16. Feel nauseous, queasy or gag easily 1-Mild	16. Feel nauseous, queasy or gag easily 2-Moderate	16. Feel nauseous, queasy or gag easily 3-Severe
17. Color of stools light brown or yellow	17. Color of stools light brown or yellow 0-Never	17. Color of stools light brown or yellow 1-Mild	17. Color of stools light brown or yellow 2-Moderate	17. Color of stools light brown or yellow 3-Severe
18. Greasy or high fat foods cause distress	18. Greasy or high fat foods cause distress 0-Never	18. Greasy or high fat foods cause distress 1-Mild	18. Greasy or high fat foods cause distress 2-Moderate	18. Greasy or high fat foods cause distress 3-Severe
19. Pain between shoulder blades	19. Pain between shoulder blades 0-Never	19. Pain between shoulder blades 1-Mild	19. Pain between shoulder blades 2-Moderate	19. Pain between shoulder blades 3-Severe
20. Dark circles under eyes	20. Dark circles under eyes 0-Never	20. Dark circles under eyes 1-Mild	20. Dark circles under eyes 2-Moderate	20. Dark circles under eyes 3-Severe
21. "Acid" breath	21. "Acid" breath 0-Never	21. "Acid" breath 1-Mild	21. "Acid" breath 2-Moderate	21. "Acid" breath 3-Severe
22. History of gallbaldder attacks or gallstones	22. History of gallbaldder attacks or gallstones 0-Never	22. History of gallbaldder attacks or gallstones 1-Mild	22. History of gallbaldder attacks or gallstones 2-Moderate	22. History of gallbaldder attacks or gallstones 3-Severe
23. Appetite reduced	23. Appetite reduced 0-Never	23. Appetite reduced 1-Mild	23. Appetite reduced 2-Moderate	23. Appetite reduced 3-Severe
Section C:	Section C: 0-Never	Section C: 1-Mild	Section C: 2-Moderate	Section C: 3-Severe
24. Coated tongue or "fuzzy" debris on tongue	24. Coated tongue or "fuzzy" debris on tongue 0-Never	24. Coated tongue or "fuzzy" debris on tongue 1-Mild	24. Coated tongue or "fuzzy" debris on tongue 2-Moderate	24. Coated tongue or "fuzzy" debris on tongue 3-Severe
25. Pass large amounts of foul smelling gas	25. Pass large amounts of foul smelling gas 0-Never	25. Pass large amounts of foul smelling gas 1-Mild	25. Pass large amounts of foul smelling gas 2-Moderate	25. Pass large amounts of foul smelling gas 3-Severe
26. Irritable bowel or mucous colitis	26. Irritable bowel or mucous colitis 0-Never	26. Irritable bowel or mucous colitis 1-Mild	26. Irritable bowel or mucous colitis 2-Moderate	26. Irritable bowel or mucous colitis 3-Severe
27. Constipation, diarrhea alternating or stools alternate from soft to watery	27. Constipation, diarrhea alternating or stools alternate from soft to watery 0-Never	27. Constipation, diarrhea alternating or stools alternate from soft to watery 1-Mild	27. Constipation, diarrhea alternating or stools alternate from soft to watery 2-Moderate	27. Constipation, diarrhea alternating or stools alternate from soft to watery 3-Severe
28. Bowel movements painful or difficult, constipation, and/or laxatives used	28. Bowel movements painful or difficult, constipation, and/or laxatives used 0-Never	28. Bowel movements painful or difficult, constipation, and/or laxatives used 1-Mild	28. Bowel movements painful or difficult, constipation, and/or laxatives used 2-Moderate	28. Bowel movements painful or difficult, constipation, and/or laxatives used 3-Severe
29. burning or itching anus	29. burning or itching anus 0-Never	29. burning or itching anus 1-Mild	29. burning or itching anus 2-Moderate	29. burning or itching anus 3-Severe

	0-Never	1-Mild	2-Moderate	3-Severe
103. Frequent skin rashes and/or hives	*Category V Section A: 103. Frequent skin rashes and/or hives 0-Never	103. Frequent skin rashes and/or hives 1-Mild	103. Frequent skin rashes and/or hives 2-Moderate	103. Frequent skin rashes and/or hives 3-Severe
104. Muscle-leg-toe cramping at rest and/or while sleeping	104. Muscle-leg-toe cramping at rest and/or while sleeping 0-Never	104. Muscle-leg-toe cramping at rest and/or while sleeping 1-Mild	104. Muscle-leg-toe cramping at rest and/or while sleeping 2-Moderate	104. Muscle-leg-toe cramping at rest and/or while sleeping 3-Severe
105. Fever easily raised/fevers common	105. Fever easily raised/fevers common 0-Never	105. Fever easily raised/fevers common 1-Mild	105. Fever easily raised/fevers common 2-Moderate	105. Fever easily raised/fevers common 3-Severe
106. Crave Chocolate	106. Crave Chocolate 0-Never	106. Crave Chocolate 1-Mild	106. Crave Chocolate 2-Moderate	106. Crave Chocolate 3-Severe
107. Feet have bad odor	107. Feet have bad odor 0-Never	107. Feet have bad odor 1-Mild	107. Feet have bad odor 2-Moderate	107. Feet have bad odor 3-Severe
108. Hoarseness frequent	108. Hoarseness frequent 0-Never	108. Hoarseness frequent 1-Mild	108. Hoarseness frequent 2-Moderate	108. Hoarseness frequent 3-Severe
109. Difficulty swallowing	109. Difficulty swallowing 0-Never	109. Difficulty swallowing 1-Mild	109. Difficulty swallowing 2-Moderate	109. Difficulty swallowing 3-Severe
110. Joint stiffness after rising	110. Joint stiffness after rising 0-Never	110. Joint stiffness after rising 1-Mild	110. Joint stiffness after rising 2-Moderate	110. Joint stiffness after rising 3-Severe
111. Vomiting frequent	111. Vomiting frequent 0-Never	111. Vomiting frequent 1-Mild	111. Vomiting frequent 2-Moderate	111. Vomiting frequent 3-Severe
112. Tendency to anemia	112. Tendency to anemia 0-Never	112. Tendency to anemia 1-Mild	112. Tendency to anemia 2-Moderate	112. Tendency to anemia 3-Severe
113. "Whites" of eyes (sclera) blue	113. "Whites" of eyes (sclera) blue 0-Never	113. "Whites" of eyes (sclera) blue 1-Mild	113. "Whites" of eyes (sclera) blue 2-Moderate	113. "Whites" of eyes (sclera) blue 3-Severe
114. "Lump" in throat	114. "Lump" in throat 0-Never	114. "Lump" in throat 1-Mild	114. "Lump" in throat 2-Moderate	114. "Lump" in throat 3-Severe
115. Dry mouth-eyes-nose	115. Dry mouth-eyes-nose 0-Never	115. Dry mouth-eyes-nose 1-Mild	115. Dry mouth-eyes-nose 2-Moderate	115. Dry mouth-eyes-nose 3-Severe
116. White spots on finger nails	116. White spots on finger nails 0-Never	116. White spots on finger nails 1-Mild	116. White spots on finger nails 2-Moderate	116. White spots on finger nails 3-Severe
117. Cuts heal slowly and/or scar easily	117. Cuts heal slowly and/or scar easily 0-Never	117. Cuts heal slowly and/or scar easily 1-Mild	117. Cuts heal slowly and/or scar easily 2-Moderate	117. Cuts heal slowly and/or scar easily 3-Severe
118. Reduced or "lost" sense of taste and/or smell	118. Reduced or "lost" sense of taste and/or smell 0-Never	118. Reduced or "lost" sense of taste and/or smell 1-Mild	118. Reduced or "lost" sense of taste and/or smell 2-Moderate	118. Reduced or "lost" sense of taste and/or smell 3-Severe
119. Susceptible to colds, fevers and/or infections	119. Susceptible to colds, fevers and/or infections 0-Never	119. Susceptible to colds, fevers and/or infections 1-Mild	119. Susceptible to colds, fevers and/or infections 2-Moderate	119. Susceptible to colds, fevers and/or infections 3-Severe
120. Strong light irritates eyes	120. Strong light irritates eyes 0-Never	120. Strong light irritates eyes 1-Mild	120. Strong light irritates eyes 2-Moderate	120. Strong light irritates eyes 3-Severe
121. Noises in head or ringing ears	121. Noises in head or ringing ears 0-Never	121. Noises in head or ringing ears 1-Mild	121. Noises in head or ringing ears 2-Moderate	121. Noises in head or ringing ears 3-Severe
122. Burning sensations in mouth	122. Burning sensations in mouth 0-Never	122. Burning sensations in mouth 1-Mild	122. Burning sensations in mouth 2-Moderate	122. Burning sensations in mouth 3-Severe
123. Numbness in hands and feet (extremities "go to sleep")	123. Numbness in hands and feet (extremities "go to sleep") 0-Never	123. Numbness in hands and feet (extremities "go to sleep") 1-Mild	123. Numbness in hands and feet (extremities "go to sleep") 2-Moderate	123. Numbness in hands and feet (extremities "go to sleep") 3-Severe
124. Intolerant to monosodium glutamate (MSG)	124. Intolerant to monosodium glutamate (MSG) 0-Never	124. Intolerant to monosodium glutamate (MSG) 1-Mild	124. Intolerant to monosodium glutamate (MSG) 2-Moderate	124. Intolerant to monosodium glutamate (MSG) 3-Severe
125. Cannot recall dreams	125. Cannot recall dreams 0-Never	125. Cannot recall dreams 1-Mild	125. Cannot recall dreams 2-Moderate	125. Cannot recall dreams 3-Severe
126. Nose bleeds frequent	126. Nose bleeds frequent 0-Never	126. Nose bleeds frequent 1-Mild	126. Nose bleeds frequent 2-Moderate	126. Nose bleeds frequent 3-Severe
127. Bruise easily, "black and blue" spots	127. Bruise easily, "black and blue" spots 0-Never	127. Bruise easily, "black and blue" spots 1-Mild	127. Bruise easily, "black and blue" spots 2-Moderate	127. Bruise easily, "black and blue" spots 3-Severe
128.Muscle cramps, worse with exercise ("charley horses")	128.Muscle cramps, worse with exercise ("charley horses") 0-Never	128.Muscle cramps, worse with exercise ("charley horses") 1-Mild	128.Muscle cramps, worse with exercise ("charley horses") 2-Moderate	128.Muscle cramps, worse with exercise ("charley horses") 3-Severe

Health Assessment FormExit this survey

1. Default Section

*1. Please provide the following information:

2. Who referred you to this site?

*3. Date of Birth

4. Mark any of the following medications you are taking:

5. Mark if you eat, drink or use:

6. Mark if you:

7. Please list your five major health concerns in order of importance.

8. Please list medication and supplements you currently take.

*9. Category ISection A:

*10. Category II

*11. Category IIISection A

*12. Section B

*13. Category IVSection A:

*14. Section B

*15. Section C

*16. Section D

*17. Section E

*18. Section F

*19. Category VSection A:

*20. Category VI

21. Category VIIFemale Only

22. Category VIIIMale Only