Evaluate Your Health

Posted by in News, Nutrition

    Part 1:

    Please List 3 major health concerns in your order of importance:

    1:
    2:
    3:

    Part 2:

    Please check the appropriate box on all questions below.

    Colon Health

    Diarrhea:
    NeverSometimesAlways


    Constipation:
    NeverSometimesAlways

    Fuzzy or white coating of the tongue:
    NeverSometimesAlways

    Passing of foul smelling gas:
    NeverSometimesAlways

    Use of laxatives frequently:
    NeverSometimesAlways

    Digestive Function

    Excess belching, bloating or burping:
    NeverSometimesAlways


    Stomach pain within 1-3 hours following a meal:
    NeverSometimesAlways

    Offensive breath:
    NeverSometimesAlways

    Sense of fullness during and after meals:
    NeverSometimesAlways

    Use of antacids:
    NeverSometimesAlways

    Blood Sugar

    Crave sweets during the day:
    NeverSometimesAlways


    Agitated, frequently upset or nervous:
    NeverSometimesAlways

    Difficulty losing weight:
    NeverSometimesAlways

    Increased thirst and appetite:
    NeverSometimesAlways

    Frequent urination:
    NeverSometimesAlways

    Mental fogginess:
    NeverSometimesAlways

    Adrenal Function

    Difficulty falling or staying asleep:
    NeverSometimesAlways


    Crave Salt:
    NeverSometimesAlways

    Afternoon fatigue:
    NeverSometimesAlways

    Dizziness upon standing up:
    NeverSometimesAlways

    Afternoon headaches:
    NeverSometimesAlways

    Gallbladder Function

    Have you had your gallbladder removed:
    NeverSometimesAlways


    Unexplained itchy skin:
    NeverSometimesAlways

    Bitter or metallic taste in your mouth, especially in the morning:
    NeverSometimesAlways

    Do you have bouts of nausea and or vomiting:
    NeverSometimesAlways

    Colicky pain following high fat meals:
    NeverSometimesAlways

    Hormone Regulation

    Hot flashes:
    NeverSometimesAlways


    Depression:
    NeverSometimesAlways

    Disinterest in Sex:
    NeverSometimesAlways

    Acne:
    NeverSometimesAlways

    Facial hair growth:
    NeverSometimesAlways

    Hair loss/thinning:
    NeverSometimesAlways

    Alternating menstrual cycle length:
    NeverSometimesAlways

    Part 3:

    Your Name (required)

    Your Email (required)

    Additional Info

    Post a Reply

    Your email address will not be published. Required fields are marked *