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Home >> Online Survey

SYMPTOM SURVEY FORM

From the Symptom Survey we can determine the nutritional deficiencies you have and then make recommendations as to the whole food supplements you need.  Analysis of Symptom Survey is $25.00.  Make sure you follow the instructions.

Step 1 - Please read the notice below.

Notice: If you suffer from a disease or other serious health condition you should consult a doctor in addition to any nutritional steps you take to improve your health.  This on-line service does not replace the need for personal medical advice. The purpose of this service is to help you improve health through natural and personalized nutrition. Although tests can detect many health conditions,  there is no claim that you will be cured of any medical condition. Your goal here should be to address the current nutritional needs of your body and thereby improve the potential of your body to heal itself and respond favorably to any medical treatment you receive.


STEP 2

Click the "Add to Shopping Cart" button and then return to this page by clicking on 'Continue Shopping'. 

STEP 3

Fill in the following form.  The results will be emailed to you at the address you give below.

Health Assessment
Required fields are in red.
First Name:
Middle Name:
Last Name:
Birth Date: Day: Month: Year: 19
Sex: Male Female
Email:
Confirm Email:
Telephone:
Fax:
 
Address Line 1:
Address Line 2:
City:
State/Province:
Zip/Postal Code:
Country:
 
Delivery Options: Fax Mail
 
Blood Pressure: /
 
INSTRUCTIONS

Select all symptoms that apply.
When completed, click "Submit" at the end of this form.
NEVER (does not apply)
MILD (occurs once or twice a year)
MODERATE (occurs several times a year)
SEVERE (you are aware of it almost constantly)
Group 1
1. Acid foods upset Never Mild Moderate Severe
2. Chilled often Never Mild Moderate Severe
3. "Lump" in throat Never Mild Moderate Severe
4. Dry mouth - eyes - nose Never Mild Moderate Severe
5. Pulse races after meals Never Mild Moderate Severe
6. Keyed up - fails to calm Never Mild Moderate Severe
7. Cuts heal slowly Never Mild Moderate Severe
8. Gags - retches easily Never Mild Moderate Severe
9. Unable to relax; startles easily Never Mild Moderate Severe
10. Extremities cold, clammy Never Mild Moderate Severe
11. Strong light irritates Never Mild Moderate Severe
12. Reduced urine amount Never Mild Moderate Severe
13. Heart pounds after retiring Never Mild Moderate Severe
14. "Nervous" stomach Never Mild Moderate Severe
15. Reduced Appetite Never Mild Moderate Severe
16. Cold sweats often Never Mild Moderate Severe
17. Fever easily raised Never Mild Moderate Severe
18. Nerve pains Never Mild Moderate Severe
19. Staring, blinks little – pupils dilated Never Mild Moderate Severe
20. Sour stomach frequent Never Mild Moderate Severe
Group 2
21. Joint stiffness after arising Never Mild Moderate Severe
22. Muscle leg-toe cramps at night – kicks while sleeping Never Mild Moderate Severe
23. Butterfly stomach cramps Never Mild Moderate Severe
24. Eyes or nose watery Never Mild Moderate Severe
25. Eyes blink often Never Mild Moderate Severe
26. Eyelids swollen, puffy Never Mild Moderate Severe
27. Indigestion soon after meals Never Mild Moderate Severe
28. Always seems hungry; feels lightheaded often Never Mild Moderate Severe
29. Digestion rapid Never Mild Moderate Severe
30. Frequent vomiting Never Mild Moderate Severe
31. Frequent hoarseness Never Mild Moderate Severe
32. Irregular breathing Never Mild Moderate Severe
33. Pulse slow, feels irregular Never Mild Moderate Severe
34. Gagging reflex slow Never Mild Moderate Severe
35. Difficulty swallowing Never Mild Moderate Severe
36. Constipation & diarrhea alternating Never Mild Moderate Severe
37. "Slow starter" Never Mild Moderate Severe
38. Get "chilled" easily Never Mild Moderate Severe
39. Perspires easily Never Mild Moderate Severe
40. Circulation poor, sensitive to cold Never Mild Moderate Severe
41. Subject to colds, asthma, bronchitis Never Mild Moderate Severe
Group 3
42. Eat when nervous Never Mild Moderate Severe
43. Excessive appetite Never Mild Moderate Severe
44. Hungry between meals Never Mild Moderate Severe
45. Irritable before meals Never Mild Moderate Severe
46. Trembles if hungry Never Mild Moderate Severe
47. Fatigue, eating relieves Never Mild Moderate Severe
48. Anxious, weak if meals delayed Never Mild Moderate Severe
49. Heart palpitates if meals missed or delayed Never Mild Moderate Severe
50. Afternoon headaches Never Mild Moderate Severe
51. Overeating sweets upsets Never Mild Moderate Severe
52. Awaken after a few hours sleep - hard to get back to sleep Never Mild Moderate Severe
53. Craves candy in the afternoon Never Mild Moderate Severe
54. Moods of depression - "blues" or melancholy Never Mild Moderate Severe
55. Abnormal craving for sweets or treats Never Mild Moderate Severe
Group 4
56. Hands and feet go to sleep easily, numbness Never Mild Moderate Severe
57. Sigh frequently, air hunger Never Mild Moderate Severe
58. Aware of "breathing heavily" Never Mild Moderate Severe
59. High altitude discomfort Never Mild Moderate Severe
60. Opens window in closed room Never Mild Moderate Severe
61. Susceptible to colds and fever Never Mild Moderate Severe
62. Afternoon "Yawner" Never Mild Moderate Severe
63. Drowsy often Never Mild Moderate Severe
64. Swollen ankles, worse at night Never Mild Moderate Severe
65. Muscle cramps, worse during exercise; get "charley horses" Never Mild Moderate Severe
66. Shortness of breath on exertion Never Mild Moderate Severe
67. Dull pain in chest - or radiating from left arm, worse on exertion Never Mild Moderate Severe
68. Bruise easily, black & blue spots Never Mild Moderate Severe
69. Tendency to anemia Never Mild Moderate Severe
70. Frequent nose bleeds Never Mild Moderate Severe
71. Noises in head or ringing in ears Never Mild Moderate Severe
72. Tension under the breastbone or feeling of tightness, worse on exertion Never Mild Moderate Severe
Group 5
73. Dizziness Never Mild Moderate Severe
74. Dry skin Never Mild Moderate Severe
75. Burning Feet Never Mild Moderate Severe
76. Blurred vision Never Mild Moderate Severe
77. Itching skin and feet Never Mild Moderate Severe
78. Excessive hair falling Never Mild Moderate Severe
79. Frequent skin rashes Never Mild Moderate Severe
80. Bitter, metallic taste in mouth in mornings Never Mild Moderate Severe
81. Bowel movements painful or difficult Never Mild Moderate Severe
82. Worrier, feels insecure Never Mild Moderate Severe
83. Feeling queasy; headache over eyes Never Mild Moderate Severe
84. Greasy food upset Never Mild Moderate Severe
85. Stools light-colored Never Mild Moderate Severe
86. Skin peels on soles of feet Never Mild Moderate Severe
87. Pain between shoulder blades Never Mild Moderate Severe
88. Uses Laxatives Never Mild Moderate Severe
89. Stools alternate from soft to watery Never Mild Moderate Severe
90. History of gallbladder attacks or gallstones Never Mild Moderate Severe
91. Sneezing attacks Never Mild Moderate Severe
92. Dreaming, nightmare type dreams Never Mild Moderate Severe
93. Bad breath (halitosis) Never Mild Moderate Severe
94. Milk products distress Never Mild Moderate Severe
95. Sensitive to hot weather Never Mild Moderate Severe
96. Burning or itching anus Never Mild Moderate Severe
97. Craves Sweets Never Mild Moderate Severe
Group 6
98. Loss of taste for meat Never Mild Moderate Severe
99. Lower bowel gas several hours after eating Never Mild Moderate Severe
100. Burning stomach, eating relieves Never Mild Moderate Severe
101. Coated tongue Never Mild Moderate Severe
102. Large amounts of foul smelling gas Never Mild Moderate Severe
103. Indigestion 1/2 to 1 hour after eating; may be up to 3 hrs. Never Mild Moderate Severe
104. Mucus colitis or irritable bowel Never Mild Moderate Severe
105. Gas shortly after eating Never Mild Moderate Severe
106. Stomach bloating after eating Never Mild Moderate Severe
Group 7A
107. Insomnia Never Mild Moderate Severe
108. Nervousness Never Mild Moderate Severe
109. Can't gain weight Never Mild Moderate Severe
110. Intolerance to heat Never Mild Moderate Severe
111. Highly emotional Never Mild Moderate Severe
112. Flush Easily Never Mild Moderate Severe
113. Night Sweats Never Mild Moderate Severe
114. Thin, moist skin Never Mild Moderate Severe
115. Inward trembling Never Mild Moderate Severe
116. Heart palpitates Never Mild Moderate Severe
117. Increased appetite without weight gain Never Mild Moderate Severe
118. Pulse fast at rest Never Mild Moderate Severe
119. Eyelids and face twitch Never Mild Moderate Severe
120. Irritable and restless Never Mild Moderate Severe
121. Can't work under pressure Never Mild Moderate Severe
Group 7B
122. Increase in weight Never Mild Moderate Severe
123. Decrease in appetite Never Mild Moderate Severe
124. Fatigue easily Never Mild Moderate Severe
125. Ringing in Ears Never Mild Moderate Severe
126. Sleep during day Never Mild Moderate Severe
127. Sensitive to cold Never Mild Moderate Severe
128. Dry or scaly skin Never Mild Moderate Severe
129. Constipation Never Mild Moderate Severe
130. Mental Sluggishness Never Mild Moderate Severe
131. Hair coarse, tails out Never Mild Moderate Severe
132. Headaches upon arising wear off during day Never Mild Moderate Severe
133. Slow pulse, below 65 Never Mild Moderate Severe
134. Frequent urination Never Mild Moderate Severe
135. Impaired hearing Never Mild Moderate Severe
136. Reduced Initiative Never Mild Moderate Severe
Group 7C
137. Failing memory Never Mild Moderate Severe
138. Low blood pressure Never Mild Moderate Severe
139. Increased Sex Drive Never Mild Moderate Severe
140. Headaches, splitting or severe Never Mild Moderate Severe
141. Decreased sugar tolerance Never Mild Moderate Severe
Group 7D
142. Abnormal thirst Never Mild Moderate Severe
143. Abdominal Bloat Never Mild Moderate Severe
144. Weight gain around hips or waist Never Mild Moderate Severe
145. Sex drive reduced or lacking Never Mild Moderate Severe
146. Tendencies to ulcers and colitis Never Mild Moderate Severe
147. Increased sugar tolerance Never Mild Moderate Severe
148. Women: Menstrual Disorders Never Mild Moderate Severe
149. Young girls: lack of menstrual function Never Mild Moderate Severe
Group 7E
150. Dizziness Never Mild Moderate Severe
151. Headaches Never Mild Moderate Severe
152. Hot Flashes Never Mild Moderate Severe
153. Increased blood pressure Never Mild Moderate Severe
154. Hair growth on face or body (female) Never Mild Moderate Severe
155. Sugar in urine (not diabetes) Never Mild Moderate Severe
156. Masculine tendencies (female) Never Mild Moderate Severe
Group 7F
157. Weakness, dizziness Never Mild Moderate Severe
158. Chronic Fatigue Never Mild Moderate Severe
159. Low blood pressure Never Mild Moderate Severe
160. Nails weak and rigid Never Mild Moderate Severe
161. Tendency to hives Never Mild Moderate Severe
162. Arthritic tendencies Never Mild Moderate Severe
163. Perspiration increase Never Mild Moderate Severe
164. Bowel disorders Never Mild Moderate Severe
165. Poor circulation Never Mild Moderate Severe
166. Swollen ankles Never Mild Moderate Severe
167. Crave salt Never Mild Moderate Severe
168. Brown spots or bronzing of skin Never Mild Moderate Severe
169. Allergies tendency to asthma Never Mild Moderate Severe
170. Weakness after illness Never Mild Moderate Severe
171. Exhaustion - muscular and nervous Never Mild Moderate Severe
172. Respiratory disorders Never Mild Moderate Severe
FEMALE ONLY
Skip to Male Section
173. Very easily fatigued Never Mild Moderate Severe
174. Premenstrual Tension Never Mild Moderate Severe
175. Painful Menses Never Mild Moderate Severe
176. Depressed feelings before menstruation Never Mild Moderate Severe
177. Menstruation excessive and prolonged Never Mild Moderate Severe
178. Painful breasts Never Mild Moderate Severe
179. Menstruation excessive and prolonged Never Mild Moderate Severe
180. Vaginal Discharge Never Mild Moderate Severe
181. Hysterectomy/ovaries removed Never Mild Moderate Severe
182. Hot Flashes Never Mild Moderate Severe
183. Menses scanty or missed Never Mild Moderate Severe
184. Acne worse at menses Never Mild Moderate Severe
185. Depression of long standing Never Mild Moderate Severe
MALE ONLY
Skip to Next Section
186. Prostate trouble Never Mild Moderate Severe
187. Urination difficult or dribbling Never Mild Moderate Severe
188. Night urination frequent Never Mild Moderate Severe
189. Depression Never Mild Moderate Severe
190. Pain on inside of legs or heels Never Mild Moderate Severe
191. Feeling of incomplete bowel evacuation Never Mild Moderate Severe
192. Lack of energy Never Mild Moderate Severe
193. Migrating aches and pains Never Mild Moderate Severe
194. Tire too easily Never Mild Moderate Severe
195. Avoids activity Never Mild Moderate Severe
196. Leg nervousness at night Never Mild Moderate Severe
197. Diminished sex drive Never Mild Moderate Severe
Comments  

Type up to five health complaints in order of importance.