Health Evaluation

Welcome to your Health Evaluation. Please answer the following questions accurately. The results will determine which product suits your needs best.

For questions labelled 0-10, please answer according to the severity of the health problem (0=unnoticeable, 5=mild and 10=severe).

Please enter your name *

Please enter your email *

Please enter your phone number *

Who referred you to this Health Evaluation?

What are your health-related goals? *

How badly do you suffer from high blood pressure:

0 1 2 3 4 5 6 7 8 9 10

How severely do you experience back pain, neck pain, or arthritis?

0 1 2 3 4 5 6 7 8 9 10

How often do you experience stiff shoulders and headaches?

0 1 2 3 4 5 6 7 8 9 10

How often do you experience numbness, or feet/arms falling asleep?

0 1 2 3 4 5 6 7 8 9 10

How much trouble do you have falling asleep?

0 1 2 3 4 5 6 7 8 9 10

How badly do you suffer from bleeding gums of cavities?

0 1 2 3 4 5 6 7 8 9 10

How severely do you suffer from kidney stones or bone spurs:

0 1 2 3 4 5 6 7 8 9 10

How badly do you suffer from knee, shoulder or joint pain?

0 1 2 3 4 5 6 7 8 9 10

Do you take painkiller medication?

Yes No

Do you take blood pressure medication?

Yes No

Do you suffer from Cardiovascular Disease, Eczema, or PMS?

Yes

No

Are you forgetful?

Always

Often

Ocassionally

Rarely

Never

How often do you have trouble breathing?

Always

Often

Ocassionally

Rarely

Never

Do you have eye or eyesight problems?

Always

Often

Ocassionally

Rarely

Never

Do you have age spots or blemishes?

Yes

No

Do you have gray hair, wrinkles or hemorrhoids?

Yes

No

Do you take cholesterol medication

Yes

No

Do you take blood thinners or diuretics?

Yes

No

Do you take fibromyalgia or MS medication?

Yes

No

Do you take Alzheimer or Parkinson medication?

Yes

No

How severely do you suffer from ADD/ADHD, Depression, or Diabetes?

0 1 2 3 4 5 6 7 8 9 10

How often do you get sleepy after meals?

0 1 2 3 4 5 6 7 8 9 10

How often do you have cravings for sugar or sweets?

0 1 2 3 4 5 6 7 8 9 10

How often do you sweat excessively or have excessive thirst

0 1 2 3 4 5 6 7 8 9 10

How often do you wake up during the night?

0 1 2 3 4 5 6 7 8 9 10

How much trouble do you have with losing weight?

0 1 2 3 4 5 6 7 8 9 10

Do you have trouble controlling your blood sugar levels?

0 1 2 3 4 5 6 7 8 9 10

Do you take blood sugar medication?

No Yes

Do you take mood swing medication?

No Yes

Do you take ADD, ADHD, or autism medication?

No Yes

How badly do you suffer from food sensitivities, heartburn, or indigestion?

0 1 2 3 4 5 6 7 8 9 10

How badly do you suffer from stomach or intestinal pain?

0 1 2 3 4 5 6 7 8 9 10

How often do you experience Bloating or Gas?

0 1 2 3 4 5 6 7 8 9 10

How badly do experience allergies?

0 1 2 3 4 5 6 7 8 9 10

How frequently do you have Constipation or Diarrhea?

0 1 2 3 4 5 6 7 8 9 10

Do you have immune system problems/get sick often?

0 1 2 3 4 5 6 7 8 9 10

Do you take anti-acids or stomach meds?

No Yes

Do you take fibre or medication for constipation?

No Yes

Do you take medication for Crohn's Disease?

No Yes

Do you take immune system medication?

No Yes

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