FREE Health Quiz — Symptom Information Form

Take this FREE health quiz to find out what nutritional supplement you need to help your body overcome candida, intestinal parasites, chronic fatigue, hypoglycemia, prostate problems, menopause, pms, thyroid problems, and other common health problems.

This FREE health questionnaire will help isolate vitamin deficiencies and provide nutrition information on natural vitamin and mineral supplements especially for you. Just fill it out, and your FREE personalized health program will be sent to you by U. S. Mail.

Privacy: 

The information you provide is treated in the strictest confidence. Your communication is absolutely private and no portion of your personal information will ever be shared.  The results will be emailed to the email address you provide below. 

Instructions: 

First, enter your name, age, sex and contact information.

Then in the boxes below, for those which apply to you, enter either a 1,2 or 3, where:

"1"  is for MILD symptoms (symptoms you've had some time in the last year)
"2"  is for MODERATE symptoms (you've had some time in the last six months)
"3"  is for SEVERE symptoms (those bothering you now)

Leave a box BLANK if it does not apply to you or if you don't know.

Name:
Birthdate:
Sex: Male          Female
Email:
(Required for your response)
Phone
Address: 
City:
State/Province:   
Zip/Postal Code:
Country  

Please enter either a 1,2 or 3, as above:

Group 1

1.      Acid foods upset
2.      Get chilled, often
3.      "Lump" in throat
4.      Dry mouth-eyes-nose
5.      Pulse speeds after meals
6.      Keyed up - fail to calm
7.      Cuts heal slowly
8.      Gag easily
9.      Unable to relax; startle easily
10.    Extremities cold, clammy
11.    Strong light irritates
12.    Urine amount reduced
13.    Heart pounds after retiring
14.    "Nervous" stomach
15.    Appetite reduced
16.    Cold sweats often
17.    Fever easily raised
18.    Neuralgia-like pains
19.    Staring, blink little
20.    Sour stomach frequent

Group 2

21.    Joint stiffness after arising
22.    Muscle-leg-toe cramps at night
23.    "Butterfly" stomach
24.    Eyes or nose watery
25.    Eyes blink often
26.    Eyelids swollen, puffy
27.    Indigestion soon after meals
28.    Always seem hungry; feel "lightheaded" often
29.    Digestion rapid
30.    Vomiting rapid
31.    Hoarseness frequent
32.    Breathing irregular
33.    Pulse slow; feels "irregular"
34.    Gagging reflex slow
35.    Difficulty swallowing
36.    Constipation, diarrhea alternating
37.    "Slow starter"
38.    Get "chilled" infrequently
39.    Perspire easily
40.    Circulation poor, sensitive to cold
41.    Subject to colds, asthma bronchitis

Group 3

42.    Eat when nervous
43.    Excessive appetite
44.    Hungry between meals
45.    Irritable before meals
46.    Get "shaky" if hungry
47.    Fatigue, eating relieves
48.    "Lightheaded" if meals delayed
49.    Heart palpitates if meals missed or delayed
50.    Afternoon headaches
51.    Overeating sweets upsets
52.    Awaken after few hours sleep-hard to get   back to sleep
53.    Crave candy or coffee in afternoons
54.    Moods of depression-"blues" or melancholy
55.    Abnormal craving for sweets or snacks

Group 4

56.    Hands & feet go to sleep easily, numbness
57.    Sigh frequently, "air hunger"
58.    Aware of "breathing heavily"
59.    High altitude discomfort
60.    Open windows in closed room
61.    Susceptible to colds and fevers
62.    Afternoon "yawner"
63.    Get "drowsy" often
64.    Swollen ankles worse at night
65.    Muscle cramps, worse during exercise; get "charley horses"
66.    Shortness of breath on exertion
67.    Dull pain in chest or radiating into left arm, worse on exertion
68.    Bruise easily, "black/blue" spots
69.    Tendency to anemia
70.    "Nose bleeds" frequent
71.    Noises in head or "ringing in ears"
72.    Tension under the breastbone, or feeling of "tightness", worse on exertion

Group 5

73 .   Dizziness
74.    Dry skin
75.    Burning feet
76.    Blurred vision
77.    Itching skin and feet
78.    Excessive falling hair
79.    Frequent skin rashes
80.    Bitter, metallic taste in mouth in mornings
81.    Bowel movements painful or difficult
82.    Worrier, feel insecure
83.    Feeling queasy; headache over eyes
84.    Greasy foods upset
85.    Stools light-colored
86.    Skin peels on foot soles
87.    Pain between shoulder blades
88.    Use laxatives
89.    Stools alternate from soft to watery
90.    History of gallbladder attacks or gallstones
91.    Sneezing attacks
92.    Dreaming, nightmare type bad dreams
93.    Bad breath (halitosis)
94.    Milk products cause distress
95.    Sensitive to hot weather
96.    Burning or itching anus
97.    Crave sweets

Group 6

98.      Loss of taste for meat
99.      Lower bowel gas several hours after eating
100.    Burning stomach sensations, eating relieves
101.    Coated tongue
102.    Pass large amounts of foul-smelling gas.
103.    Indigestion 1/2-1 hour after eating; may be up to 3-4 hours
104.    Mucus colitis or "irritable bowel"
105.    Gas shortly after eating
106.    Stomach "bloating" after eating

Group 7 - (A)

107.    Insomnia
108.    Nervousness
109.    Can't gain weight
110.    Intolerance to heat
111.    Highly emotional
112.    Flush easily
113.    Night sweats
114.    Thin, moist skin
115.    Inward trembling
116.    Heart palpitates
117.    Increased appetite without weight gain
118.    Pulse fast at rest
119.    Eyelids and face twitch
120.    Irritable and restless
121.    Can't work under pressure

Group 7 - (B)

122.    Increase in weight
123.    Decrease in appetite
124.    Fatigue easily
125.    Ringing in ears
126.    Sleepy during day
127.    Sensitive to cold
128.    Dry or scaly skin
129.    Constipation
130.    Mental sluggishness
131.    Hair coarse, falls out
132.    Headaches upon arising wear off during day
133.    Slow pulse, below 65
134.    Frequency of urination
135.    Impaired hearing
136.    Reduced initiative

Group 7 - (C)

137.    Failing memory
138.    Low blood pressure
139.    Increased sex drive
140.    Headaches, "splitting or rending" type
141.    Decreased sugar tolerance

Group 7 - (D)

142.    Abnormal thirst
143.    Bloating of abdomen
144.    Weight gain around hips or waist
145.    Sex drive reduced or lacking
146.    Tendency to ulcers, colitis
147.    Increased sugar tolerance
148.    Women; menstrual disorders
149.    Young girls: lack of menstrual function

Group 7 - (E)

150.    Dizziness
151.    Headaches
152.    Hot flashes
153.    Increased blood pressure
154.    Hair growth on face or body (female)
155.    Sugar in urine (not diabetes)
156.    Masculine tendencies (female)

Group 7 - (F)

157.    Weakness, dizziness
158.    Chronic fatigue
159.    Low blood pressure
160.    Nails weak, ridged
161.    Tendency to hives
162.    Arthritic tendencies
163.    Perspiration increase
164.    Bowel disorders
165.    Poor circulation
166.    Swollen ankles
167.    Crave salt
168.    Brown spots or bronzing of skin
169.    Allergies - tendency to asthma
170.    Weakness after colds, influenza
171.    Exhaustion
172.    Respiratory disorders

Female Only

173.    Very easily fatigued
174.    Premenstrual tension
175.    Painful menses
176.    Depressed feeling before menstruation
177.    Menstruation excessive and prolonged
178.    Painful breasts
179.    Menstruate too frequently
180.    Vaginal discharge
181.    Hysterectomy/ovaries removed
182.    Menopausal hot flashes
183.    Menses scanty or missed
184.    Acne, worse at menses
185.    Depression of long standing

Male Only

186.    Prostate trouble
187.    Urination difficult or dribbling
188.    Night urination frequent
189.    Depression
190.    Pain on inside of legs or heels
191.    Feeling of incomplete bowel evacuation
192.    Lack of energy
193.    Migrating aches and pains
194.    Tire too easily
195.    Avoid activity
196.    Leg nervousness at night
197.    Diminished sex drive

Important
Please list below the five main health complaints you have in order of their importance

1.   
2.   
3.   
4.   
5.   

  I am also interested in having a Hair Analysis done for a more comprehensive view of my health and nutrition situation.