BALANCING BODY CHEMISTRY HEALTH ASSESSMENT

Transcription

1 BALANCING BODY CHEMISTRY HEALTH ASSESSMENT Name: Sex: Age: Birthdate: Occupation: Height: Weight: Date: Part I Circle or darken any of the following medications you are taking: Antacids Cortisone/Anti-Inflammatories Lithium Ulcer Medications Chemotherapy Laxatives Thyroid Aspirin/Tylenol Hormones Recreational Drugs Anti-diabetic/Insulin High Blood Pressure Relaxants/Sleeping Pills Antidepressants Heart Medications Radiation Antibiotic/Antifungal Diuretics Oral Contraceptives Other Circle or darken if you eat, drink, or use: Alcohol Fluoridated/Chlorinated Water Refined Sugars Milk Products Distilled Water Margarine Coffee Artificial Sweeteners Luncheon Meats Chewing Tobacco Refined (White) Flour Products Non-Herbal Teas Carbonated Beverages Cigarettes Vitamins & Minerals Candy Eat Fast Foods Regularly Fried Foods Please Specify: Circle or darken if you: Diet Often Exposed to chemicals at work Under excessive stress Exercise less than 3 times wkly Salt food w/o tasking Exposed to cigarette smoke Directions: Please read each description and darken or circle the number which best describes the frequency of your symptoms within the past year. If you do not understand a symptom, put a? before the symptom s number. ANSWER KEY: 0 = Never 1 = Mild 2 = Moderate 3 = Severe (Occurs once a month or less) (Occurs several times monthly) (Aware of it almost constantly) PART II IMPORTANT Dear Patient. Please list your five major health concerns in order of importance: PART III CATEGORY I Score (#1 - #29) 1. Bad breath, halitosis Loss of taste for high protein foods (meat, etc.) Burning ( acid ) or nervous stomach, eating relieves Gas shortly after eating Indigestion ½ to 1 hour after eating, may last 3-4 hours Difficulty digesting fruits or vegetables, undigested Foods found in stools Acid or spicy foods upset stomach Section B: 8. Lower bowel gas and or bloating several hours after Eating Feet Burn whites of eyes (sclera) yellow Dry skin, itchy feet and/or skin peels on feet Brown spots or bronzing of skin Bitter metallic taste in mouth Blurred vision Headache over eyes Feel nauseous, queasy or gag easily Color of stools light brown or yellow Greasy or high fat foods cause distress Pain between shoulder blades Dark circles under eyes Acid Breath History of gallbladder attacks or gallstones OR gallbladder removed. YES NO 23. Appetite reduced Section C: CATEGORY II Score (#30 - # 36) 30. Head congestion/ sinus fullness Sneezing attacks Dreaming, nightmare-like bad dreams Milk products and/or wheat products cause Distress Eyes and nose watery Eyes swollen and puffy Pulse speeds after meals and/or heart pounds after retiring CATEGORY III Score (#37 - # 45) 37. Crave sweets or coffee in afternoon/mid-morning Hungry between meals or excessive appetite Overeating sweets upsets Eat when nervous Irritable before meals Get shaky or light-headed if meals delay Fatigue, eating relieves Heart palpitates if meals missed or delayed Awaken a few hours after sleep, hard to get back To sleep Section B: Score (#24- #29) 24. Coated tongue or fuzzy debris on tongue Pass large amounts of foul smelling gas Irritable bowel or mucous colitis Constipation, diarrhea alternating or stools alternate From soft to watery Bowel movements painful or difficult, constipation, And/or laxatives used Burning or itching anus Score (#46 - #51) 46. Muscle soreness after moderate exercise Vulnerability to insect bites (especially fleas and Mosquitoes) Loss of muscle tone or heaviness in arms or legs Enlarged heart and/or hear failure Worrier, feel insecure and/or highly emotional Pulse slow/below 65 or irregular pulse

2 CATEGORY IV Score (#52 - #62) 52. Sex drive increased Splitting type headaches Memory failing Tolerance for sugar reduced Section B: 56. Sex drive reduced or absent Abnormal thirst Weight gain around hips or waist Tendency to ulcers or colitis Increased ability to eat sugar without symptoms Menstrual disorders (women) Lack of menstruation (young girls) Section C: Score (#63 - #71 ) 63. Difficulty gaining weight, even if large appetite Heart palpitations Nervous, emotional, and/or can t work under pressure Insomnia Inward Trembling Night Sweats Fast pulse at rest Intolerant to high temperatures Easily flushed Section D: Score (#72 - #81) 72. Difficulty losing weight Reduced initiative and/or mental sluggishness Easily fatigued, sleepy during the day Sensitive to cold, poor circulation (cold hands and feet) Dry or scaly skin Ringing in ears/noises in head Hearing impaired Constipation Excessive falling hair and/or coarse hair Headaches when awakening/wear off during the day Section E: Score (#82 - #86) 82. Blood pressure low Headaches Hot flashes Hair growth on face or body (Question to females) Masculine tendencies (Question to females) Section F: Score (#87 - #102) 87. Blood pressure low Crave salt Chronic fatigue/get drowsy Afternoon yawning Weakness/dizziness Weakness after colds/slow recover Circulation poor Muscular and nervous exhaustion Subject to colds, asthma, bronchitis (respiratory disorders) Allergies and/or hives Difficulty maintaining manipulative correction Arthritic tendencies Nails weak, ridged Perspire easily Slow starter in morning Afternoon headaches CATEGORY V CATEGORY VI Score (#129 - #134) Aware of heavy and/or irregular breathing Discomfort in high altitudes Air hunger/sigh frequently Swollen ankles/worse at night Shortness of breath with exertion Dull pain in chest and/or paid radiating into left Arm, worse on exertion CATEGORY VII Female Only Score (135 - #146) 135. Premenstrual tension Painful menses (cramping, etc) Menstruation excessive or prolonged Painful/tender breasts Menstruate too frequently Acne, worse at menses Depressed feeling before menstruation Vaginal discharge Menses scanty or missed Hysterectomy/ovaries removed Menopausal hot flashes Depression CATEGORY VIII Male Only Score (#103 - #127) 103. Frequent skin rashes and/or hives Muscle-leg-toe cramping at rest and/or while sleeping Fever easily raised/fevers common Crave Chocolate Feet have bad odor Hoarseness frequent Difficulty swallowing Joint stiffness after rising Vomiting frequent Tendency to anemia Whites of eyes (sclera) blue Lump in throat Dry mouth-eyes-nose White spots on fingernails Cuts heal slowly and/or scar easily Reduced or lost sense of taste and/or smell Susceptible to colds, fevers, and/or infections Strong light irritates eyes Noises in head or ringing in ears Burning sensations in mouth Numbness in hands and feet (extremities go to sleep Intolerant to monosodium glutamate (MSG) Cannot recall dreams Nose bleeds frequent Bruise easily black and blue spots Muscle cramps, worse with exercise ( charley horses ) Score (#147 - #155) 147. Prostate trouble Urination difficult or dribbling Night urination frequent Pain on inside of legs or heels Feeling or incomplete bowel evacuation Leg nervousness at night Tire easily/avoid activity Reduced sex drive Depression Migrating aches and pains

3 BALANCING BODY CHEMISTRY HEALTH ASSESSMENT Name: Sex: Age: Birthdate Occupation: Height: Weight: Date: Part I Circle or darken any of the following medications you are taking: Antacids Cortisone/Anti-Inflammatories Lithium Ulcer Medications Chemotherapy Laxatives Thyroid Aspirin/Tylenol Hormones Recreational Drugs Anti-diabetic/Insulin High Blood Pressure Relaxants/Sleeping Pills Antidepressants Heart Medications Radiation Antibiotic/Antifungal Diuretics Oral Contraceptives Other Circle or darken if you eat, drink, or use: Alcohol Fluoridated/Chlorinated Water Refined Sugars Milk Products Distilled Water Margarine Coffee Artificial Sweeteners Luncheon Meats Chewing Tobacco Refined (White) Flour Products Non-Herbal Teas Carbonated Beverages Cigarettes Vitamins & Minerals Candy Eat Fast Foods Regularly Fried Foods Please Specify: Circle or darken if you: Diet Often Exposed to chemicals at work Under excessive stress Exercise less than 3 times wkly Salt food w/o tasking Exposed to cigarette smoke Directions: Please read each description and darken or circle the number which best describes the frequency of your symptoms within the past year. If you do not understand a symptom, put a "?" before the symptom's number. ANSWER KEY: 0 = Never 1 = Mild 2 = Moderate 3 = Severe (Occurs once a month or less) (Occurs several times monthly) (Aware of it almost constantly) PART II IMPORTANT Dear Patient. Please list your five major health concerns in order of importance:

4 PART III CATEGORY I Score (#1 - #29) 1. Bad breath, halitosis Loss of taste for high protein foods (meat, etc.) Burning ("acid") or nervous stomach, eating relieves Gas shortly after eating Indigestion ½ to 1 hour after eating, may last 3-4 hours Difficulty digesting fruits or vegetables, undigested Foods found in stools Acid or spicy foods upset stomach Section B: 8. Lower bowel gas and or bloating several hours after Eating Feet Burn "whites" of eyes (sclera) yellow Dry skin, itchy feet and/or skin peels on feet Brown spots or bronzing of skin Bitter metallic taste in mouth Blurred vision Headache over eyes Feel nauseous, queasy or gag easily Color of stools light brown or yellow Greasy or high fat foods cause distress Pain between shoulder blades Dark circles under eyes "Acid" Breath History of gallbladder attacks or gallstones OR gallbladder removed... YES NO 23. Appetite reduced Section C: Score (#24- #29) 24. Coated tongue or "fuzzy" debris on tongue Pass large amounts of foul smelling gas Irritable bowel or mucous colitis Constipation, diarrhea alternating or stools alternate

5 From soft to watery Bowel movements painful or difficult, constipation, And/or laxatives used Burning or itching anus CATEGORY II Score (#30 - # 36) 30. Head congestion/"sinus fullness" Sneezing attacks Dreaming, nightmare-like bad dreams Milk products and/or wheat products cause Distress Eyes and nose watery Eyes swollen and puffy Pulse speeds after meals and/or heart pounds after retiring CATEGORY III Score (#37 - # 45) 37. Crave sweets or coffee in afternoon/mid-morning Hungry between meals or excessive appetite Overeating sweets upsets Eat when nervous Irritable before meals Get "shaky" or light-headed if meals delay Fatigue, eating relieves Heart palpitates if meals missed or delayed Awaken a few hours after sleep, hard to get back To sleep Section B: Score (#46 - #51) 46. Muscle soreness after moderate exercise Vulnerability to insect bites (especially fleas and Mosquitoes) Loss of muscle tone or "heaviness" in arms or legs Enlarged heart and/or hear failure Worrier, feel insecure and/or highly emotional Pulse slow/below 65 or irregular pulse CATEGORY IV Score (#52 - #62) 52. Sex drive increased "Splitting" type headaches Memory failing Tolerance for sugar reduced

6 Section B: 56. Sex drive reduced or absent Abnormal thirst Weight gain around hips or waist Tendency to ulcers or colitis Increased ability to eat sugar without symptoms Menstrual disorders (women) Lack of menstruation (young girls) Section C: Score (#63 - #71 ) 63. Difficulty gaining weight, even if large appetite Heart palpitations Nervous, emotional, and/or can't work under pressure Insomnia Inward Trembling Night Sweats Fast pulse at rest Intolerant to high temperatures Easily flushed Section D: Score (#72 - #81) 72. Difficulty losing weight Reduced initiative and/or mental sluggishness Easily fatigued, sleepy during the day Sensitive to cold, poor circulation (cold hands and feet) Dry or scaly skin "Ringing" in ears/noises in head Hearing impaired Constipation Excessive falling hair and/or coarse hair Headaches when awakening/wear off during the day Section E: Score (#82 - #86) 82. Blood pressure low Headaches Hot flashes Hair growth on face or body (Question to females) Masculine tendencies (Question to females) Section F: Score (#87 - #102) 87. Blood pressure low Crave salt Chronic fatigue/get drowsy Afternoon yawning Weakness/dizziness

7 92. Weakness after colds/slow recover Circulation poor Muscular and nervous exhaustion Subject to colds, asthma, bronchitis (respiratory disorders) Allergies and/or hives Difficulty maintaining manipulative correction Arthritic tendencies Nails weak, ridged Perspire easily Slow starter in morning Afternoon headaches CATEGORY V Score (#103 - #127) 103. Frequent skin rashes and/or hives Muscle-leg-toe cramping at rest and/or while sleeping Fever easily raised/fevers common Crave Chocolate Feet have bad odor Hoarseness frequent Difficulty swallowing Joint stiffness after rising Vomiting frequent Tendency to anemia "Whites" of eyes (sclera) blue "Lump" in throat Dry mouth-eyes-nose White spots on fingernails Cuts heal slowly and/or scar easily Reduced or "lost" sense of taste and/or smell Susceptible to colds, fevers, and/or infections Strong light irritates eyes Noises in head or ringing in ears Burning sensations in mouth Numbness in hands and feet (extremities "go to sleep Intolerant to monosodium glutamate (MSG) Cannot recall dreams Nose bleeds frequent Bruise easily "black and blue" spots Muscle cramps, worse with exercise ("charley horses") CATEGORY VI Score (#129 - #134)

8 129. Aware of heavy and/or irregular breathing Discomfort in high altitudes Air hunger/sigh frequently Swollen ankles/worse at night Shortness of breath with exertion Dull pain in chest and/or paid radiating into left Arm, worse on exertion CATEGORY VII Score (135 - #146) Female Only 135. Premenstrual tension Painful menses (cramping, etc) Menstruation excessive or prolonged Painful/tender breasts Menstruate too frequently Acne, worse at menses Depressed feeling before menstruation Vaginal discharge Menses scanty or missed Hysterectomy/ovaries removed Menopausal hot flashes Depression CATEGORY VIII Male Only Score (#147 - #155) 147. Prostate trouble Urination difficult or dribbling Night urination frequent Pain on inside of legs or heels Feeling or incomplete bowel evacuation Leg nervousness at night Tire easily/avoid activity Reduced sex drive Depression Migrating aches and pains