1. Do you
have more than one sore throat or cold a year?
2. Do you
have sore throats, colds or bouts with flu lasting longer
than 4 days?
3. Do you
have recurring infections?
4. Are you
often short of breath without much exertion?
5. Do you
breathe heavily after climbing a long set of stairs?
6. Do you
tend to get a side ache when running or from other
7. Do you
have respiratory allergies (eg., pollen, fumes)?
8. Do you
have or suspect you have food allergies?
9. Is your
your heart rate become rapid with only slight exertion?
your heart beat flutter at times?
you had a heart attack?
you had a stroke?
your hands and/or feet often cold?
15. Do your
ankles, feet or hands swell (water retention)?
16. Do you
sometimes have tingling, burning or numbness in your
hands, arms, legs or feet?
17. Do you
have frequent nervous twitches?
18. Do you
feel seriously stressed by your circumstances?
19. Are you
a nervous person?
20. Do you
often feel tense?
21. Do you
at times feel depressed?
22. Are you
anxious about possible events?
23. Do you
get irritated easily?
24. Are you
forgetful or confused?
25. Do you
have a hard time concentrating?
26. Are you
27. Do you
have a hard time getting up in the morning?
28. Do you
get light-headed when hungry?
29. Do you
get headaches frequently?
30. Do you
ever feel dizzy or off balance?
eating improve the way you feel?
32. Do you
find yourself bingeing at times?
33. Do you
seek stimulation from coffee, alcohol, candy, etc.?
34. Does it
seem that you are thirsty overly much?
35. Do you
have high energy soon after consuming sweets?
36. Are you
tired or sleepy a while after consuming sweets or
37. Are you
38. Are you
39. Do you
have difficulty reducing weight, if needed?
40. Do you
need assistance to reduce weight?
41. Are you
42. Do you
have or think you might have an eating disorder?
43. Is it
hard to gain weight even though you are eating well?
44. Do you
have frequent indigestion?
45. Do you
have stomach gas, feel bloated, or belch after meals or
46. Do you
get stomach aches?
47. Do you
have an intestinal gas problem (flatulence)?
48. Are you
sometimes constipated (bowels hard to move well)?
Do your bowels move less than 2 times a day?
your bowels move less than once a day?
Do your bowels move more than 3 times per day?
you have frequent diarrhea (loose watery stools)?
51. Do you
commonly have an excessive urgency to move your bowels?
your rectum itch occasionally?
food take more than 15 hours to pass through?
54. Do your
stools have a overly foul odor?
55. Do your
stools have a light color and float?
56. Is your
stool sticky (leaving anal residue) frequently?
fiber foods bother you?
58. Do you
get leg cramps?
59. Do you
have calcium deposits?
60. Do you
have soft or brittle bones?
61. Have you had a
lot of dental caries & cavities?
62. Do you have
silver fillings in your teeth?
63. Do you
have sore or sensitive gums?
64. Do you ever
have jaw popping or pain in the jaw?
65. Is your
66. Do you
chew more on one side of the mouth?
67. Do you feel
the need to urinate more frequently than normal?
68. Do you
have trouble initiating urination?
69. Do you
have trouble expelling urine thoroughly?
70. Are you
71. Do you
have trouble falling asleep or sleeping deeply?
72. Do you
have a halitosis ("bad breath") problem?
73. Do you
have periods of hyperactivity?
74. (Female) a) Do you have PMS problems?
you menopausal or post menopausal?
(Female) Have you had vaginal yeast problems?
(Female) Have you had swelling or lumps in a breast?
77. (Female) a) Have you given birth to children?
you currently pregnant or nursing?
PERFORMANCE (male or female)
78. Do you
have a diminished sex drive?
79. Is the
duration of your sexual arousal insufficient?
there any ruptured blood vessels in the whites of your
your eyes abnormally sensitive to light or wind?
82. Do you
83. Do cuts
& bruises heal slowly?
84. If you
cut yourself, is the bleeding slow to stop?
85. Do you
have excessively dry skin and/or hair, and/or brittle
nails, and/or dry mouth?
86. Do you
87. Do you
smoke 1/2 pack per day or more?
88. Do you
smoke a pack per day or more?
89. Do you
drink more than one cup of coffee per day?
90. Do you
drink alcoholic beverages more than 2 times per week?
91. Do you
drink more than 2 alcoholic drinks in a day or evening?
Do you drink and cook with unfiltered tap water?
you bathe and/or shower in unfiltered tap water?
93. Do you
drink less than 40 oz. of pure water per day?
94. Do you
drink more than 2 cans of soda pop per week?
95. Do you
eat sugar, candy, ice cream, baked goodies, etc.?
96. Do you
often consume items with Nutrasweet(tm) / Aspartame(tm)
97. Do you
consume less than one cup of raw vegetables and one cup
of raw fruits daily?
98. Do you
consume more than 4 cups of dairy milk per week?
99. Do you
eat more than 4 servings of cheese, yogurt, sour cream
and/or ice cream per week?
you try to eat a concentrated protein food (meat, fish,
milk, cheese, eggs, nuts, seeds) at every meal?
you consume "red" meat (beef, pork, lamb,
venison, etc.) more than 3 times per week?
you eat processed meats (weiners, sausage, pepperoni,
you eat more than 3 servings a week of white flour
products (white bread, rolls, pasta, etc.)?
you eat less than 3 servings per week of whole grain
foods (whole wheat bread, brown rice, oatmeal, barley,
you eat products made from soybeans more than once a
you regularly consume more than one of these foods in the
same meal: meat, fish, cheese, egg, cereal, bread, pasta,
rice, fruit/fruit juice, sweets?
you drink beverages with meals?
you use salt or salted foods?
you consume "junk" foods and "junk"
you skip breakfast?
you snack between meals and/or in the evening?
you commonly eat late in the evening?
you a vegetarian?
you cook some of your food in a microwave oven?
you in an electronic field very much of the time (eg., on
a computer, near utility wires, etc.)?
you walk briskly or exercise aerobically for at least 20
minutes LESS than 3 times a week?
you have a serious medical condition for which you are
currently under a physician's treatment?
you currently taking any medications?
you take vitamins regularly?
you take 500 mg. or more of Vitamin C daily?
you take Vitamin E regularly?
you take other antioxidants regularly?
you take B-vitamins or a multi-vitamin regularly?
you take extra calcium regularly?
you take extra magnesium regularly?
you take a "trace mineral" product regularly?
you consume "superfoods" (eg. spirulina and/or
cereal grasses) daily?
you take herbal products regularly?
you take supplemental enzymes regularly?
you consume foods or supplements rich in Omega 3 fatty
Indicate any of the following conditions that have been
identified as a concern for you by clicking on the box:
Arthritis - Osteo
Arthritis - Rheumatoid
Pressure High or Hypertension
Cholesterol High b) Triglycerides High
Carpal Tunnel Syndrome
Chronic Fatigue Syndrome
Cravings For Junk Foods
Digestive Tract Problems
Diverticulosis / Diverticulitis
"Heartburn" / Acid Reflux
Irritable Bowel Syndrome
Headaches -- Migraines
Hernia -- Hiatal
Hernia -- Abdominal
Hypoglycemia (Low Blood Sugar)
Immune System Weakness
Menstrual Cramps (Female)
Prostate Gland Problems (Male)
Throat -- Excess Mucus
Throat -- Recurring Infection
Urinary Tract Problems
Inflammation / Infection
OTHER PERSONAL INFORMATION
Please Record (if known)
223. Are you a a) male or a b) female?
ft. 5 in. or below
ft. 6 in. - 4ft. 9 in
ft.10 in. - 5 ft. 1 in.
ft. 2 in. - 5 ft. 5 in.
ft. 6 in. - 5 ft. 9 in.
ft.10 in. - 6 ft. 1 in.
ft. 2 in. - 6 ft. 5 in.
ft. 6 in. - 6 ft. 9 in.
ft.10 in. - 7 ft.1 in.
ft. 2 in. or over
under 80 lbs.
227. Eye Color:
228. Original Hair Color:
230. Ethnic background:
(NOTE: You may indicate more than one, but limit to major
influences. This information is
not required. You may choose not to give it.)
Central or Northern European
Please provide us with at least your name and the valid
e-mail address where you receive e-mail and read it,
which should be the same e-mail address you use for
Your Valid E-mail Address
If someone referred you to us, please enter their name
(if known) and their e-mail address.
What is their name? (if known)
What is their E-mail Address?
If you have completed the Wellness Quiz to your
satisfaction and entered the needed personal information,
please read the following "Disclaimer", then
CLICK ON the "SUBMIT" button below.
The educational information offered in The
Wellness Report is based solely on
the indications provided by the client in their responses
to the questions in The Wellness
Quiz . The report is not a medical
diagnosis. The information provided is drawn from the
author's more than 27 years of experience in the natural
health field, including writing five books; and the
current level of research and knowledge available to him.
This information is not a substitute for consulting a
qualified health care practitioner.
The client is advised to make use of the Wellness Report
judiciously on their own responsibility. There is no
warranty regarding the results of using this information,
and the author and publisher disclaim any liability for
the actions of the client.
JUST A FEW DAYS
Your Wellness Quiz
and personal information will be forwarded to us. We will
process it and respond with your Wellness
Report within one to three business
days (excluding weekends and holidays).
If you are ready to submit your responses and other
information, CLICK ON the "SUBMIT" button.
(NOTE: For greater confidentiality of your responses,
only the Quiz numbers are being transmitted, not the word
If you would like to clear the Quiz form, either to start
over or for a new person to take the Quiz, the
"RESET" button has been provided for that