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Wellness Profile Questionnaire

Tab from one field to the next. Enter data, if known and as appropriate in each field

Full Name:
Address:
City:
State:
Zip Code:
E-mail:
Phone:
Fax:
Age:
Sex:		Male Female
Blood Pressure:
Total Cholesterol:
HDL:
LDL:
Height:
Weight:
Date:
List ALL Medications you take:

Instructions

Please select the appropriate answers below. Please answer ALL "Yes" or "No" questions! If a statement does not apply please select "Does Not Apply". (Some questions are repeated in different sessions to insure proper scoring)

Yes	No	Trying to loose weight?
Yes	No	Interested in preventing Cancer?
Yes	No	Exercise frequently?
Yes	No	Want to strengthen the immune system?
Yes	No	Eat vegetarian diet?
Yes	No	Are you overweight?
Yes	No	Eat less than 3 servings per day of milk, yogurt or cheese?
Yes	No	Eat fried and processed foods?
Yes	No	Eat less than 3-5 servings of vegetables daily?
Yes	No	Eat low fiber, high fat diet?
Yes	No	Eat less than 6-11 servings of whole grain daily?
Yes	No	Eat less than 2 servings of fruit daily?
Yes	No	Are you pregnant?
Yes	No	Interested in preventing Heart Disease?
Yes	No	Do you have High Blood Pressure?
Yes	No	Do you have Type 1 Diabetes or medically diagnosed Reactive Hypogglycemia?
Yes	No	Do you or does anyone in your immediate household smoke?
Yes	No	Do you have high cholesterol?
Yes	No	Do you have joint or muscle aches or tenderness, OR abnormal muscle aches from exercise OR backache?

Points Section

Section 1

		Acne, Blackheads or Warts?
		Dry, Rough Skin?
		Poor Appetite.
		Permanent Goose Bumps on back of arms.
		Inability to adjust eyes when entering a dark room. Difficulty seeing at night.
		Frequent Colds, Respiratory Infections.

Section 2

		Frequent Fatigue
		Irritability
		Depression
		Craving for Sweets
		Can't Concentrate
		Fits of Temper
		Hurt all over (General)
		Heart Palpitations
		Graying Hair
		Use antibiotics, eat red meat or chicken, drink milk

Section 3

		Bleeding Gums
		Bruise Easily
		Frequent Colds or Flu
		Varicose Veins or Broken Capillaries
		Slow healing of Cuts or Scrapes
		Nose Bleeds
		Cuticles Tear Easily, Hang Nails

Section 5

		Poor Circulation
		Lack of Stamina
		Dark Circles under Eyes
		History of Anemia
		Heavy Menstral Flow
		Thin, Fragile, Brittle Nails
		Pale Skin, Palms very Pale

Section 6

		Menstral Cramps
		Muscle Twitching or Tics
		Fingernails won't Grow
		Foot or Leg Cramps
		Insomnia
		Muscle Tension
		Joints Pop or Crack
		Frequent Backaches
		Aching Joints or Muscles
		Crave Chocolate

Section 7

		Bad Breath
		White Coated Tongue
		White Spots on Fingernails
		Diminished Smell or Taste
		Slow Healing of Wounds
		Stress
		Yes No — Taking Estrogen (The pill or Premarin)

Section 10

		Nausia, Headaches, Migraine
		History of Constipation
		Bad Breath, Bad Taste in Mouth
		History of Hepatitus, Jaundice, Malaria
		Occasional Body Oder, Including Feet
		Undigested food in Bowl Movement
		Gall Bladder or Stones Removed. — Year
		Frequent Tension in Neck and Shoulders
		Occasional Abdominal Pain after a big meal
		Coated Tongue
		Yellow-colored Bowel Movements
		Ingest Alcohol (more than 1 oz. OR 1 beer per day)

Section 11

		History of Colitis, Diverticulitis
		Desire to eat often, Especially Starches
		History of Hemorrhoids
		Alternating Constipation and Diarrhea
		Constipation durring Menstration
		Thin, Pencil-like Bowel Movements
		Painful, Hard Bowel Movements
		History of Rectal Fissure
		Rarely have Daily Bowel Movements

Section 12

		Gas after eating
		Stomach Bloating after Eating
		Belching, Burping after meals

Section 12A

		Heavy, Tired feeling after eating
		Drowsey after eating
		Very Flabby Tissue
		Fingernails break and split
		Chronic Fluid Retention

Section 14

		Stomach Pain 5-6 Hours after Meals, often at Night. Relieved by Drinking Cream or Milk
		Above Complaints aggrevated by Worry and Tension. Relieved by Vacationing.
		Taking Pills or Vitamins causes Stomach Discomfort
		History of Ulcers

Section 16

		Puffy Eyes
		Ankles Swell Frequently
		History of Kidney or Bladder Infections
		Difficult or painful Urination
		Infrequent Urination
		Legs often feel Heavy
		Sleep Disturbed by Urge to Urinate 2 or More times each Night
		Severe Pre-Menstrual Bloating

Section 17

		Blood Pressure Fluctuates, Sometimes too Low
		Craving for Salt
		Overly Worried or Concerned about things left Undone
		Occasional Cold Sweats
		Constriction in Throat, Lump that Hurts when Emotionally Disturbed
		Perfectionist, Set High Standards
		Emotional Upsets cause Exhaustion. Must go and Lie Down
		Eyes Sensitive to Headlights and Sun
		Easily Startled, Heart Pounds from Unexpected Noise
		Allergies, Skin Rash, Hay Fever, Sneezing Attacks

Section 18

(FEMALE—Complete this section then proceed to Section 20
(MALE—Skip this Section, Procede to Section 19)

		Missing Periods
		Irregular or Uncomfortable Periods
		Menopause, Hot Flashes,Night Sweats
		Feel Nervouse, Depressed before Periods
		Diminished Sex Drive
		Mood Changes
		Abnormal Sleep Patterns
		Yes No — Had Overies or Uterus Removed (Hystorectomy)? Year

Section 19

(MALE—Complete this Section then proceede to Section 20
FEMALE—Skip this section, Proceed directly to Section 20)

		Prostate Trouble
		Difficulty Urinating, Starting, Burning
		Diminished Sex Drive
		Get Up At Night to Urinate
		Back or Leg Pains

Section 20

		Irritable if Late for a Meal or Missing a Meal
		Urinate a Lot
		Wake Up at Night feeling Hungry
		Emotional on an Empty Stomach
		Craving for sweets, Alcohol or Coffee
		Intense, Frequent Thirst
		Cold Sweats on Hands even when Warm
		Irritable Before Breakfast
		Nervouse, Shakey Feeling, Headaches relieved by eating Sweets or Starches
		Weak Spells, Tiredness in Mid-Afternoon
		Bouts of Faintness, Dizziness, lack of Concentration .

Section 21

		Crave Starches and Sweets, but eating doesn't provide much relief.
		Occasional Night Sweats
		History of Sores, Especially in Legs, Slow Healing
		Diabetes in Family
		Chronic Fatigue, Lowered Resistance
		Very Thirsty all of the Time

Section 22

		Feel Better when Resting, Low Exercise Tolerance, Low Endurance
		Require Extra Amount of Sleep
		Bruise Easily, Black and Blue Spots
		Short of Breath when Climbing Stairs
		Cold Hands and Feet, Need Extra Covers at Night

Section 22A

		Numbness or Heaviness in Arms or Legs
		Hands Cramp when Writing
		Tingling Sensation in Lips or Fingers
		Memory Getting Worse
		Short Walks cause Aches and Pains
		Arms and Legs often go to sleep

Section 22B

		Chest Pains, Sometimes Down Left Arm
		Heart Sometimes Flip-Flops
		Very Slow Heart Beat (under 50/minute)
		Unexplained Headache or Dizziness
		Shortness of Breath on Exertion
		Diabetes
		Very Rapid Heart Beat (over 90/minute)
		History of Heart Disease in Family

Section 25

		History of Bronchitis, Asthma, Pneumonia, Emphysema, Pleurisy
		Chronic Cough
		Working in a Factory, or with Chemicals or Fumes
		History of Colds, Lung Problems
		Chronic Mucus in Throat or Sinus

Section 26

		History of Cancer, Multiple Sclerosis, Parkinsons, Rheumatoid Arthritis
		Unusual Number of Cavities
		Swolen Glands in Groin, Tonsils, Throat, Armpits
		Very Susceptible to Infection
		Flu-like Symptoms often occur
		Feel Puffiness in Throat

Section 27

		Frequent Use of Antibiotics
		Chronic Diarrhea
		Rectal Itching
		Bladder Infections
		Abnormal Muscle Aches from Exercise
		Feel Tired a Lot
		Severe Reaction to Tobacco, Perfume, Chemical Odors
		Unexpected Weight Gain
		Hives, Psoriasis, Acne, Skin Rashes
		Endometriosis / Ovary Problems
		Recurrent Heartburn / Digestive Upsets
		Crave Sugars, Breads, Alcohol
		Gas, Abdominal Bloating
		Are you answering ALL of the questions? If yes then give yourself a BIG pat on the back.

Section 28

		Fluid Retention
		Anemia
		Low Hormone Levels
		Nausea or Dizziness
		Weakness in General
		Premature Aging
		Slow Recovery of Wounds / Illness
		Low Resistance to Infection
		High Stress Lifestyle
		Did you put your Name on the form and answer all of the questions at the beginning? If so, give yourself a pat on the back!

Section 29

(If this section does not apply to you, proceed to section 30)
Do the following occur within 14 days before menstrual period?

		Headaches
		Weight Gain
		Increased Appetite
		Frequent Crying
		Bloating
		Depression
		Fatigue
		Brest Tenderness
		Swelling Hands and Feet
		Backache
		Nervous Tension, Irritability
		Confusion
		Crave Sweets
		Forgetfulness
		Cramps

Section 30

		Low Energy
		Caffine addiction
		Stress
		Poor Immunity
		Chronic Illness
		Poor Endurance

Section 31

		Atherosclerosis
		Irregular Heart Beat
		Chronic Heart Failure
		High Blood Pressure
		Poor Mental Alertness
		Memory Loss

Section 32

		Joint Pain and / or Tenderness
		Swollen Joints
		Cartilage Degeneration
		Decreased Mobility
		Osteoarthritis

Section 33

Yes No Are you exposed to Chemicals or Chemical Fumes?

Section 34

		Motion Sickness: sea, car, plane, etc.
		Morning Sickness
		Gas, Indigestion
		Abdominal Cramps
		Diarrhea
		Nausea

Section 35

		Chronic Fatigue or Sluggishness
		Mood Swings
		Excessive Crying
		Suicidal Thoughts
		Lack of Drive or Motivation
		Persistant Sadness or Empty Feeling

Section 36

		Anxiety
		Nervousness
		Exaustion
		Insomnia
		Muscle Tension, Fibromyalgia
		Headache, Migraines
		ADD, Learning Disorder, Hyperactivity
		Nervous Tension

Section 37

		Excessive Hair Loss
		Thinning Hair
		Dandruff
		Hair Breaks Easily
		Hair Won't Grow

Section 38

Yes	No	Are you interested in preventing Respiratory Diseases?
Yes	No	Are you interested in preventing Heart Disease?
Yes	No	Are you interested in preventing Cancer?
Yes	No	Do you have a mold or similar problem in your home?
Yes	No	Do you or does anyone in your immediate household have allergies?
Yes	No	Do you or does anyone in your immediate household smoke?
Yes	No	Are you interested in the quality of the indoor air in your home?

Instructions:

Please press the "SUBMIT" button only once. This is a long form and it will take a few moments to process all of the information.

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