Health Assessment
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Please complete all of the information below (all are required):
First Name
Last Name
Address
City, Sate, Zip
Phone
Email
Please select the consumption level of the following foods per week:
How much of each of the following do you consume daily:
Water
Vegetables
Fruits
Please briefly describe your main complaints.
Please list the medications and supplements you are currently taking and why. Short answers will suffice, i.e. Synthroid - Thyroid, Vit E - Heart.
For each of the following 140+ questions, please select the number from 0 to 4 if you are currently experiencing any of the listed symptoms. A "0" would mean that the symptom is insignificant or never experienced, and a "4" would mean that the symptom is very significant or is consistently experienced.
DIGESTION AND DETOXIFICATION1. Bad breath, halitosis
Bad breath, halitosis2. Loss of taste for high protein foods (meat, etc.)
Loss of taste for high protein foods (meat, etc.)3. Burning (“acid”) or nervous stomach, eating relieves
Burning (“acid”) or nervous stomach, eating relieves4. Gas shortly after eating
Gas shortly after eating5. Indigestion ½ to 1 hour after eating, may last 3-4 hours
Indigestion ½ to 1 hour after eating, may last 3-4 hours6. Difficulty digesting fruits or veg., undigested foods found in stools
Difficulty digesting fruits or veg., undigested foods found in stools7. Acid or spicy foods upset stomach
Acid or spicy foods upset stomach8. Lower bowel gas and or bloating several hours after eating
Lower bowel gas and or bloating several hours after eating9. Feet burn
Feet burn10.“whites” of eyes (sclera) is yellow
“whites” of eyes (sclera) is yellow11.Itchy feet and/or skin peels on feet
Itchy feet and/or skin peels on feet12.Brown spots or bronzing of skin
Brown spots or bronzing of skin13.Bitter metallic taste in mouth
Bitter metallic taste in mouth14.Blurred vision
Blurred vision15.Headache over eyes
Headache over eyes16.Feel nauseous, queasy or gag easily
Feel nauseous, queasy or gag easily17.Color of stools light brown or yellow
Color of stools light brown or yellow18.Greasy or high fat foods cause distress
Greasy or high fat foods cause distress19.Pain between shoulder blades
Pain between shoulder blades20.Dark circles under eyes
Dark circles under eyes21.“acid” breath
“acid” breath22.History or gallbladder attacks/gallstones/gallbladder removed
History or gallbladder attacks/gallstones/gallbladder removed23.Appetite reduced
Appetite reduced24.Coated tongue or “fuzzy” debris on tongue
Coated tongue or “fuzzy” debris on tongue25.Pass large amounts of foul smelling gas
Pass large amounts of foul smelling gas26.Irritable bowel or mucous colitis
Irritable bowel or mucous colitis27.Diarrhea or soft stools regularly
Diarrhea or soft stools regularly28.Bowel movements difficult, Constipation, and/or use laxatives
Bowel movements difficult, Constipation, and/or use laxatives29.Burning or itching anus
Burning or itching anus30.Head congestion/ “sinus fullness”
Head congestion/ “sinus fullness”31.Sneezing attacks
Sneezing attacks32.Nightmare-like bad dreams
Nightmare-like bad dreams33.Milk products cause distress
Milk products cause distress34.Wheat products cause distress
Wheat products cause distress35.Eyes and nose watery
Eyes and nose watery36.Eyes swollen and puffy
Eyes swollen and puffy37.Pulse speeds after meals and/or heart pounds after retiring
Pulse speeds after meals and/or heart pounds after retiring38.Arthritic tendencies
Arthritic tendencies39.Circulation poor
Circulation poor40.Aware of heavy and/or irregular breathing
Aware of heavy and/or irregular breathing41.Sigh frequently
Sigh frequently42.Swollen ankles/worse at night
Swollen ankles/worse at night43.Shortness of breath with exertion
Shortness of breath with exertion44.Dull pain in chest and/or radiation into left arm, worse on exertion
Dull pain in chest and/or radiation into left arm, worse on exertion45.Loss of muscle tone or “heaviness” in arms or legs
Loss of muscle tone or “heaviness” in arms or legs46.Enlarged heart and/or heart failure
Enlarged heart and/or heart failureVITAMIN AND MINERAL DEFICIENCY1. Bright light bothers eyes (wear sunglasses often)
Bright light bothers eyes (wear sunglasses often)2. Crave sweets or coffee in the afternoon or mid-morning
Crave sweets or coffee in the afternoon or mid-morning3. Hungry between meals or excessive appetite
Hungry between meals or excessive appetite4. Overeating sweets upsets
Overeating sweets upsets5. Eat when nervous
Eat when nervous6. Irritable before meals
Irritable before meals7. Get “shaky” or light-headed if meals delay
Get “shaky” or light-headed if meals delay8. Fatigue, eating relieves
Fatigue, eating relieves9. Heart palpitates if meals missed or delayed
Heart palpitates if meals missed or delayed10.Awaken a few hours after sleep, hard to get back to sleep
Awaken a few hours after sleep, hard to get back to sleep11.Muscle soreness after moderate exercise
Muscle soreness after moderate exercise12.Vulnerability to insect bites (especially fleas and mosquitoes)
Vulnerability to insect bites (especially fleas and mosquitoes)13.Worrier, feel insecure and/or highly emotional
Worrier, feel insecure and/or highly emotional14.Pulse slow/below 65 or irregular pulse
Pulse slow/below 65 or irregular pulse15.Frequent skin rashes and/or hives
Frequent skin rashes and/or hives16.Muscle-leg-toe cramping at rest and/or while sleeping
Muscle-leg-toe cramping at rest and/or while sleeping17.Fever easily raised/fevers common
Fever easily raised/fevers common18.Crave chocolate
Crave chocolate19.Feet have bad odor
Feet have bad odor20.Hoarseness frequent
Hoarseness frequent21.Difficulty swallowing
Difficulty swallowing22.Joint swelling after rising
Joint swelling after rising23.Vomiting frequent
Vomiting frequent24.Tendency to anemia
Tendency to anemia25.“whites” of eyes (sclera) blue
“whites” of eyes (sclera) blue26.“lump” in throat
“lump” in throat27.Dry mouth-eyes-nose
Dry mouth-eyes-nose28.Whites spots on finger nails
Whites spots on finger nails29.Cuts heal slowly and/or scar easily
Cuts heal slowly and/or scar easily30.Reduced or “lost” sense of taste and/or smell
Reduced or “lost” sense of taste and/or smell31.Susceptible to colds, fevers, and/or infections
Susceptible to colds, fevers, and/or infections32.Noises in head or ringing in ears
Noises in head or ringing in ears33.Burning sensations in mouth
Burning sensations in mouth34.Numbness in hands and feet (extremities “go to sleep”)
Numbness in hands and feet (extremities “go to sleep”)35.Intolerant to monosodium glutamate (MSG)
Intolerant to monosodium glutamate (MSG)36.Cannot recall dreams
Cannot recall dreams37.Nose bleeds frequent
Nose bleeds frequent38.Bruise easily, “black and blue” spots
Bruise easily, “black and blue” spots39.Muscle cramps, worse with exercise (“charley horses”)
Muscle cramps, worse with exercise (“charley horses”)40.Blood pressure low
Blood pressure low41.Crave salt
Crave salt42.Chronic fatigue/get drowsy
Chronic fatigue/get drowsy43.Afternoon yawning
Afternoon yawning44.Weakness/dizziness
Weakness/dizziness45.Weakness after colds/slow recovery
Weakness after colds/slow recovery46.Muscular and nervous exhaustion
Muscular and nervous exhaustion47.Subject to asthma, bronchitis (respiratory disorders)
Subject to asthma, bronchitis (respiratory disorders)48.Trouble falling asleep
Trouble falling asleep49.Difficulty maintaining manipulative correction
Difficulty maintaining manipulative correction50.Nails weak, ridged
Nails weak, ridged51.Perspire easily
Perspire easily52.Slow starter in morning
Slow starter in morning53.Afternoon headaches
Afternoon headachesHORMONAL IMBALANCES1. Sex drive increased
Sex drive increased2. “Splitting” type headaches
“Splitting” type headaches3. Memory failing
Memory failing4. Tolerance for sugar reduced
Tolerance for sugar reduced5. Sex drive reduced or absent
Sex drive reduced or absent6. Abnormal thirst
Abnormal thirst7. Weight gain around hips or waist
Weight gain around hips or waist8. Tendency to ulcers or colitis
Tendency to ulcers or colitis9. Increased ability to eat sugar without symptoms
Increased ability to eat sugar without symptoms10.Mood swings
Mood swings11.Emotionally sensitive (cry easily)
Emotionally sensitive (cry easily)12.Difficulty gaining weight, even if large appetite
Difficulty gaining weight, even if large appetite13.Heart palpitations
Heart palpitations14.Nervous, emotional, and/or can’t work under pressure
Nervous, emotional, and/or can’t work under pressure15.Insomnia
Insomnia16.Inward trembling
Inward trembling17.Night sweats
Night sweats18.Fast pulse at rest
Fast pulse at rest19.Intolerant to high temperatures
Intolerant to high temperatures20.Easily flushed
Easily flushed21.Difficulty losing weight
Difficulty losing weight22.Reduced initiative and/or mental sluggishness
Reduced initiative and/or mental sluggishness23.Easily fatigued, sleepy during the day
Easily fatigued, sleepy during the day24.Sensitive to cold, poor circulation (cold hands and feet)
Sensitive to cold, poor circulation (cold hands and feet)25.Dry or scaly skin
Dry or scaly skin26.“ringing” in ears/noises in head
“ringing” in ears/noises in head27.Hearing impaired
Hearing impaired28.Constipation
Constipation29.Excessive falling hair and/or coarse hair
Excessive falling hair and/or coarse hair30.Headaches when awaken/wear off during day
Headaches when awaken/wear off during day31.Blood pressure increased
Blood pressure increased32.Headaches
Headaches33.Hot flashes
Hot flashes34.Hair growth on face or body (females)
Hair growth on face or body (females)35.Masculine tendencies (females)
Masculine tendencies (females)FEMALE ONLY1. Premenstrual tension
Premenstrual tension2. Painful menses (cramping, etc.)
Painful menses (cramping, etc.)3. Menstruation excessive or prolonged
Menstruation excessive or prolonged4. Painful/tender breasts
Painful/tender breasts5. Menstruate too frequently
Menstruate too frequently6. Acne, worse at menses
Acne, worse at menses7. Depressed feelings before menstruation
Depressed feelings before menstruation8. Vaginal discharge
Vaginal discharge9. Menses scanty or missed
Menses scanty or missed10.Hysterectomy/ovaries removed
Hysterectomy/ovaries removed11.Menopausal hot flashes
Menopausal hot flashes12.Depression
DepressionMALE ONLY1. Prostate trouble
Prostate trouble2. Urination difficult or dribbling
Urination difficult or dribbling3. Night urination frequent
Night urination frequent4. Pain on inside of legs or heels
Pain on inside of legs or heels5. Feeling of incomplete bowel evacuation
Feeling of incomplete bowel evacuation6. Leg nervousness at night
Leg nervousness at night7. Tire easily/avoid activity
Tire easily/avoid activity8. Reduced sex drive
Reduced sex drive9. Depression
Depression10.Migrating aches and pains
Migrating aches and painsNow that you have completed the questionnaire, if you feel that there are more details you would like to provide that were not asked above, please type them in the box below. When you are finished, please click the "submit" button.
Soda
Coffee
Juices
Tea
Alcohol
Milk
Breads
Fried Foods
Pasta
Potato Chips
Chocolate
Nuts
Candy
Referred by?
Emotional stress level?
Current weight?
Age
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Do you exercise?
# of Children
Energy level?
Please list any traumas including major injuries (broken bones, car accidents) and surgeries.
Occupation
