IMMUNE
SYSTEM
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?
RESPIRATORY
SYSTEM
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
physical exertion?
7. Do you
have respiratory allergies (eg., pollen, fumes)?
8. Do you
have or suspect you have food allergies?
CIRCULATORY
SYSTEM
9. Is your
heartbeat irregular?
10. Does
your heart rate become rapid with only slight exertion?
11. Does
your heart beat flutter at times?
12. Have
you had a heart attack?
13. Have
you had a stroke?
EXTREMITIES
14. Are
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?
NERVES
& BRAIN
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?
COMMON
PROBLEMS
26. Are you
frequently tired?
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?
31. Does
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
starches?
WEIGHT
PROBLEMS
37. Are you
overweight?
38. Are you
excessively overweight?
39. Do you
have difficulty reducing weight, if needed?
40. Do you
need assistance to reduce weight?
41. Are you
underweight?
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?
DIGESTIVE
SYSTEM
44. Do you
have frequent indigestion?
45. Do you
have stomach gas, feel bloated, or belch after meals or
snacks?
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)?
49. a)
Do your bowels move less than 2 times a day?
b) Do
your bowels move less than once a day?
50. a)
Do your bowels move more than 3 times per day?
b) Do
you have frequent diarrhea (loose watery stools)?
51. Do you
commonly have an excessive urgency to move your bowels?
52. Does
your rectum itch occasionally?
53. Does
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?
57. Do
fiber foods bother you?
MINERALS
58. Do you
get leg cramps?
59. Do you
have calcium deposits?
60. Do you
have soft or brittle bones?
DENTAL
PROBLEMS
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
bite irregular?
66. Do you
chew more on one side of the mouth?
URINARY
SYSTEM
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?
OTHER
PROBLEMS
70. Are you
weak muscled?
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?
FEMALE
CONDITIONS
74. (Female) a) Do you have PMS problems?
b) Are
you menopausal or post menopausal?
75.
(Female) Have you had vaginal yeast problems?
76.
(Female) Have you had swelling or lumps in a breast?
77. (Female) a) Have you given birth to children?
b) Are
you currently pregnant or nursing?
SEXUAL
PERFORMANCE (male or female)
78. Do you
have a diminished sex drive?
79. Is the
duration of your sexual arousal insufficient?
EYES
80. Are
there any ruptured blood vessels in the whites of your
eyes?
81. Are
your eyes abnormally sensitive to light or wind?
SKIN
PROBLEMS
82. Do you
bruise easily?
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?
LIFESTYLE
PROBLEMS
86. Do you
smoke?
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?
WATER
92. a)
Do you drink and cook with unfiltered tap water?
b) Do
you bathe and/or shower in unfiltered tap water?
93. Do you
drink less than 40 oz. of pure water per day?
FOOD
CHOICES
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)
in them?
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?
100. Do
you try to eat a concentrated protein food (meat, fish,
milk, cheese, eggs, nuts, seeds) at every meal?
101. Do
you consume "red" meat (beef, pork, lamb,
venison, etc.) more than 3 times per week?
102. Do
you eat processed meats (weiners, sausage, pepperoni,
baloney, etc.)?
103. Do
you eat more than 3 servings a week of white flour
products (white bread, rolls, pasta, etc.)?
104. Do
you eat less than 3 servings per week of whole grain
foods (whole wheat bread, brown rice, oatmeal, barley,
etc.)?
105. Do
you eat products made from soybeans more than once a
week?
106. Do
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?
107. Do
you drink beverages with meals?
108. Do
you use salt or salted foods?
109. Do
you consume "junk" foods and "junk"
snacks regularly?
110. Do
you skip breakfast?
111. Do
you snack between meals and/or in the evening?
112. Do
you commonly eat late in the evening?
113. Are
you a vegetarian?
114. Do
you cook some of your food in a microwave oven?
OTHER
HEALTH CONCERNS
115. Are
you in an electronic field very much of the time (eg., on
a computer, near utility wires, etc.)?
116. Do
you walk briskly or exercise aerobically for at least 20
minutes LESS than 3 times a week?
117. Do
you have a serious medical condition for which you are
currently under a physician's treatment?
118. Are
you currently taking any medications?
NUTRITIONAL
SUPPLEMENTS
119. Do
you take 2000 IU or more of vitamin D3 daily?
120. Do
you take 500 mg. or more of Vitamin C daily?
121. Do
you take Vitamin E regularly?
122. Do
you take other antioxidants regularly?
123. Do
you take B-vitamins or a multi-vitamin regularly?
124. Do
you take extra calcium regularly?
125. Do
you take extra magnesium regularly?
126. Do
you take a "trace mineral" product regularly?
127. Do
you consume "superfoods" (eg. spirulina, cereal grass juice or
powder, etc.) daily?
128. Do
you take herbal products regularly?
129. Do
you take supplemental enzymes regularly?
130. Do
you consume foods or supplements rich in Omega 3 fatty
acids regularly?
KNOWN
HEALTH CONDITIONS
Indicate any of the following conditions that have been
identified as a concern for you by clicking on the box:
131.
"Age Spots"
132. Aging
133. AIDS
or HIV
134.
Allergies
135.
Alzheimer's
136.
Anemia
137.
Angina
138.
Anxiety
139.
Arthritis - Osteo
140.
Arthritis - Rheumatoid
141.
Asthma
142. Back
Pain
143.
Cancer (Type):
144.
Candida Yeast
Cardiovascular Problems
145.
Arteriosclerosis
146. Blood
Pressure High or Hypertension
147. Blood
Pressure Low
148. a)
Cholesterol High b) Triglycerides High
149. Heart
Attack
150. Heart
Weakness
151.
Mitral Valve
152. Pulse
Rate Rapid
153.
Stroke
154.
Carpal Tunnel Syndrome
155.
Cataracts
156.
Chronic Fatigue Syndrome
157.
Cravings For Junk Foods
158.
Cystic Fibrosis
159.
Depression
160.
Diabetes
Digestive Tract Problems
161.
Colitis
162.
Constipation
163.
Crohn's Disease
164.
Diarrhea (Recurring)
165.
Diverticulosis / Diverticulitis
166.
"Heartburn" / Acid Reflux
167.
Hemorrhoids
168.
Irritable Bowel Syndrome
169.
Ulcers
Ear Problems
170. Fluid
171.
Infections
172.
Hearing Loss
173.
Tinnitus (Ringing)
174.
Epilepsy
175.
Fatigue
176.
Fibromyalgia
177. Gall
Stones
178. Hair
Loss
179.
Headaches
180.
Headaches -- Migraines
181.
Hernia -- Hiatal
182.
Hernia -- Abdominal
183.
Herpes
184.
Hormonal Problems
185. Hot
Flashes
186.
Hypoglycemia (Low Blood Sugar)
187.
Immune System Weakness
188.
Insomnia
189.
Irritability
190. Liver
Problems
191. Lupus
192. Lyme
Disease
193.
Menstrual Cramps (Female)
194.
Multiple Sclerosis
195.
Muscle Cramps
196.
Muscle Soreness
197.
Osteoporosis
198.
Pancreas Problems
199.
Parkinson's
200.
Prostate Gland Problems (Male)
201.
Sciatica
202.
Sexual Dysfunction
203. Sinus
Problems
Skin Problems
204. Acne
205.
Cancer
206.
Excema
207. Rash
208.
Wrinkles
209.
Sports Injuries
210.
Sports Nutrition
211.
Stress
212.
Throat -- Excess Mucus
213.
Throat -- Recurring Infection
214.
Thyroid Problems
Urinary Tract Problems
215.
Bladder Weakness
216.
Inflammation / Infection
217.
Kidney Stones
218.
Kidney Weakness
219.
Varicose Veins
Vision Problems
220.
Macular Degeneration
221. Night
Blindness
222. Weak
Eyesight
OTHER PERSONAL INFORMATION
Please Record (if known)
223. Are you a a) male or a b) female?
224. Height:
a) 4
ft. 5 in. or below
b) 4
ft. 6 in. - 4ft. 9 in
c) 4
ft.10 in. - 5 ft. 1 in.
d) 5
ft. 2 in. - 5 ft. 5 in.
e) 5
ft. 6 in. - 5 ft. 9 in.
f) 5
ft.10 in. - 6 ft. 1 in.
g) 6
ft. 2 in. - 6 ft. 5 in.
h) 6
ft. 6 in. - 6 ft. 9 in.
i) 6
ft.10 in. - 7 ft.1 in.
j) 7
ft. 2 in. or over
225. Weight:
a)
under 80 lbs.
b)
80-100 lbs.
c)
101-120 lbs.
d)
121-140 lbs.
e)
141-160 lbs.
f)
161-180 lbs.
g)
181-200 lbs.
h)
201-220 lbs.
i)
221-240 lbs.
j)
241-260 lbs.
k)
261-280 lbs
l)
281-300 lbs.
m)
301-350 lbs.
n) over
350 lbs.
226. Age:
a) 1-9
years
b)
10-17 years
c)
18-34 years
d)
35-49 years
e)
50-59 years
f)
60-69 years
g)
70-79 years
h)
80-89 years
i)
90-99 years
j) over
100 years
227. Eye Color:
a)
Brown
b)
Hazel
c)
Green
d) Blue
228. Original Hair Color:
a)
blonde
b) red
c)
auburn
d)
brown
e)
black
229. Complexion:
a)
light (fair)
b)
moderate
c)
ruddy (reddish)
d) dark
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.)
a)
African
b)
Asian
c)
Central or Northern European
d)
Mediterranean
e)
Middle Eastern
f)
Hispanic
g)
Native American
h)
Pacific Islander
i)
Other
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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.
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