CONFIDENTIAL
Explanation of Symptom Evaluator
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Your first name: Your last name: If your email is incorrect you WILL NOT be able to receive your Report.
Your email: Sex: Male Female Date of Birth (Format mm/dd/yyyy) : Height: In inches please! Weight: In pounds please!
Your name and your responses will be strictly confidential.
Please read every question in all sections. Do not try to answer every question. Many questions should be blank, answer as accurately as possible. If your answer is No, Never or None just skip to the next question. You need only respond when your answers are one of the following choices. "Mild" symptom occurs once or twice a year, and is not happening now. "Moderate" symptom occurs several times a year, but are not happening now. "Severe" symptoms you are aware of almost constantly, or ARE happening now. "Severe" symptoms are the reason you are taking this Evaluator. "Moderate" would be considered "Severe" if it were happening right now.
Do NOT answer everything that is not "Moderate" or "Severe" as "Mild" ! Use "X" only to erase an answer to a question which should have been left blank! Clicking any "Advance" will bring the Question below it to the top of the screen. Read and/or answer ALL questions above an "Advance" before clicking it.Advance (Try this one)
Remember: Answer ONLY questions that apply to you. Use "X" ONLY to erase answers to questions answered by mistake.
1. Acid foods upset Mild Moderate Severe X
2. Get chilled, often Mild Moderate Severe X
3. "Lump" in throat Mild Moderate Severe X
4. Dry mouth-eyes-nose Mild Moderate Severe X
5. Pulse speeds after meals Mild Moderate Severe X
6. Keyed up fails to calm down Mild Moderate Severe X
7. Cuts heal slowly Mild Moderate Severe X
8. Gag easily tooth brushing or dental work gags) Mild Moderate Severe X
9. Unable to relax; startles easily Mild Moderate Severe X
10. Extremities (hands and feet); cold and clammy Mild ModerateSevere X
11. Strong light irritates (excessively irritated by bright light) Mild ModerateSevere X
12. Urine amount reduced Mild ModerateSevere X
13. Heart pounds after retiring (can feel or hear heart pounding when first going to bed) Mild ModerateSevere X
14. "Nervous" stomach (feels nauseous and as if may vomit) Mild ModerateSevere X
15. Appetite reduced Mild ModerateSevere X
16. Cold sweats often Mild ModerateSevere X
17. Fever easily raised Mild ModerateSevere X
18. Neuralgia-like pains (sharp pain along a nerve) Mild ModerateSevere X
19. Staring, blinks little Mild ModerateSevere X
20. Sour stomach frequent Mild ModerateSevere X
21. Joint stiffness after arising Mild Moderate Severe X
22. Muscle-leg-toe cramps at night Mild Moderate Severe X
23. "Butterfly" stomach, cramps Mild Moderate Severe X
24. Eyes or nose watery Mild Moderate Severe X
25. Eyes blink often Mild Moderate Severe X
26. Eyelids swollen, puffy Mild Moderate Severe X
27. Indigestion soon after meals Mild Moderate Severe X
28. Always feels hungry; feels "lightheaded" often Mild Moderate Severe X
29. Digestion rapid Mild Moderate Severe X
30. Vomiting frequent Mild Moderate Severe X
31. Hoarseness frequent Mild Moderate Severe X
32. Breathing irregular Mild Moderate Severe X
33. Pulse slow; feels "irregular" Mild Moderate Severe X
34. Gagging reflex slow Mild Moderate Severe X
35. Difficulty swallowing Mild Moderate Severe X
36. Constipation, diarrhea alternating Mild Moderate Severe X
37. "Slow starter" (can't seem to get started in the morning finally get going late at night) Mild Moderate Severe X
38. Get "chilled" infrequently Mild Moderate Severe X
39. Perspire easily Mild Moderate Severe X
40. Circulation poor, sensitive to cold Mild Moderate Severe X
41. Subject to colds, bronchitis, asthma Mild Moderate Severe X
42. Eat when nervous Mild Moderate Severe X
43. Excessive appetite Mild Moderate Severe X
44. Hungry between meals Mild Moderate Severe X
45. Irritable between meals Mild Moderate Severe X
46. Get "shaky" if hungry Mild Moderate Severe X
47. Fatigue, which eating relieves Mild Moderate Severe X
48. "Lightheaded" if meals delayed Mild Moderate Severe X
49. Heart palpitates (beats rapidly) if meals are missed or delayed Mild Moderate Severe X
50. Afternoon headaches Mild Moderate Severe X
51. Overeating sweets upsets Mild Moderate Severe X
52. Awaken after a few hours sleep, then it is difficult to get back to sleep Mild Moderate Severe X
53. Crave candy or coffee in afternoons Mild Moderate Severe X
54. Moods of depression-"blues" or melancholy Mild Moderate Severe X
55. Abnormal craving for sweets or snacks Mild Moderate Severe X
56. Hands and feet go to sleep easily, numbness Mild Moderate Severe X
57. Sigh frequently, can't get enough fresh air Mild Moderate Severe X
58. Become aware of "breathing heavily" Mild Moderate Severe X
59. Discomfort at high altitudes Mild Moderate Severe X
60. Feel as if you must open windows in closed rooms (can't get enough fresh air) Mild Moderate Severe X
61. Get colds and fevers easily Mild Moderate Severe X
62. Afternoon "yawner" Mild Moderate Severe X
63. Get "drowsy often" Mild Moderate Severe X
64. Swollen ankles, worse at night Mild Moderate Severe X
65. Muscle cramps, worse during exercise; get "charlie horses" Mild Moderate Severe X
66. Shortness of breath during exertion Mild Moderate Severe X
67. Dull pain in chest or radiating into left arm, worse on exertion Mild Moderate Severe X
68. Bruise easily, get "black and blue spots" Mild Moderate Severe X
69. Tendency to have anemia Mild Moderate Severe X
70. "Nosebleeds" frequent Mild Moderate Severe X
71. Noises in head or "ringing in ears" Mild Moderate Severe X
72. Tension under the breast bone, or feeling of "tightness", worse on exertion Mild Moderate Severe X
73. Dizziness Mild Moderate Severe X
74. Dry skin Mild Moderate Severe X
75. Burning feet Mild Moderate Severe X
76. Blurred vision Mild Moderate Severe X
77. Itching skin and feet Mild Moderate Severe X
78. Excessive falling hair Mild Moderate Severe X
79. Frequent skin rashes Mild Moderate Severe X
80. Bitter metallic taste in mouth in mornings Mild Moderate Severe X
81. Bowel movements painful or difficult Mild Moderate Severe X
82. Worrier, feels insecure Mild Moderate Severe X
83. Feeling queasy with headache over eyes Mild Moderate Severe X
84. Greasy foods upset Mild Moderate Severe X
85. Stools light colored Mild Moderate Severe X
86. Skin peels on feet bottoms Mild Moderate Severe X
87. Pain between shoulder blades Mild Moderate Severe X
88. Use laxatives Mild Moderate Severe X
89. Stools alternate from soft to watery Mild Moderate Severe X
90. History of gallbladder attacks or gallstones Mild Moderate Severe X
91. Sneezing attacks Mild Moderate Severe X
92. Dreaming, nightmare type bad dreams Mild Moderate Severe X
93. Bad breath (halitosis) Mild Moderate Severe X
94. Milk products cause distress Mild Moderate Severe X
95. Sensitive to hot weather Mild Moderate Severe X
96. Burning or itching anus Mild Moderate Severe X
97. Crave sweets Mild Moderate Severe X
98. Loss of taste for meat Mild Moderate Severe X
99. Lower bowel gas several hours after eating Mild Moderate Severe X
100. Burning stomach sensations which eating relieves Mild Moderate Severe X
101. Coated tongue Mild Moderate Severe X
102. Pass large amounts of foul-smelling gas Mild Moderate Severe X
103. Indigestion occurring from 1/2 hour to up to 3 hours after eating Mild Moderate Severe X
104. Mucous colitis or "irritable bowel" Mild Moderate Severe X
105. Gas shortly after eating Mild Moderate Severe X
106. Stomach bloating after eating Mild Moderate Severe X
107. Insomnia Mild Moderate Severe X
108. Nervousness Mild Moderate Severe X
109. Can't gain weight Mild Moderate Severe X
110. Intolerance to heat Mild Moderate Severe X
111. Highly emotional Mild Moderate Severe X
112. Flush easily Mild Moderate Severe X
113. Night sweats Mild Moderate Severe X
114. Thin, moist skin Mild Moderate Severe X
115. Inward trembling Mild Moderate Severe X
116. Heart palpitates Mild Moderate Severe X
117. Increased appetite without weight gain Mild Moderate Severe X
118. Pulse is fast while resting Mild Moderate Severe X
119. Eyelids and face twitch Mild Moderate Severe X
120. Irritable and restless Mild Moderate Severe X
121. Can't work under pressure Mild Moderate Severe X
122. Increase in weight Mild Moderate Severe X
123. Decrease in appetite Mild Moderate Severe X
124. Fatigue easily Mild Moderate Severe X
125. Ringing in ears Mild Moderate Severe X
126. Sleepy during day Mild Moderate Severe X
127. Sensitive to cold Mild Moderate Severe X
128. Dry or scaly skin Mild Moderate Severe X
129. Constipation Mild Moderate Severe X
130. Mental sluggishness Mild Moderate Severe X
131. Hair feels coarser and falls out faster than usual Mild Moderate Severe X
132. Headaches upon awakening; wear off during the day Mild Moderate Severe X
133. Slow pulse (below 65) Mild Moderate Severe X
134. Frequency of urination Mild Moderate Severe X
135. Impaired hearing Mild Moderate Severe X
136. Reduced initiative Mild Moderate Severe X
137. Failing memories Mild Moderate Severe X
138. Low blood pressure Mild Moderate Severe X
139. Increased sex drive Mild Moderate Severe X
140. Headaches, "splitting type" Mild Moderate Severe X
141. Decreased sugar tolerance Mild Moderate Severe X
142. Abnormal thirst Mild Moderate Severe X
143. Bloating of abdomen Mild Moderate Severe X
144. Weight gain around hips or waist Mild Moderate Severe X
145. Sex drive reduced or lacking Mild Moderate Severe X
146. Tendency to ulcers, colitis Mild Moderate Severe X
147. Increased sugar tolerance Mild Moderate Severe X
148. Women: menstrual disorders Mild Moderate Severe X
149. Young girls: delayed onset of menstruation Mild Moderate Severe X
150. Dizziness Mild Moderate Severe X
151. Headaches Mild Moderate Severe X
152. Hot flashes Mild Moderate Severe X
153. Increased blood pressure Mild Moderate Severe X
154. Hair growth on face or body (female) Mild Moderate Severe X
155. Sugar in urine (but not from diabetes) Mild Moderate Severe X
156. Masculine tendencies (female) Mild Moderate Severe X
157. Weakness, dizziness Mild Moderate Severe X
158. Chronic fatigue Mild Moderate Severe X
159. Low blood pressure Mild Moderate Severe X
160. Fingernails are weak and ridged Mild Moderate Severe X
161. Tendency to get hives Mild Moderate Severe X
162. Have arthritis or arthritic tendencies Mild Moderate Severe X
163. Perspiration increase Mild Moderate Severe X
164. Bowel disorders Mild Moderate Severe X
165. Poor circulation Mild Moderate Severe X
166. Swollen ankles Mild Moderate Severe X
167. Crave salt Mild Moderate Severe X
168. Brown spots or bronzing of skin Mild Moderate Severe X
169. Allergies - tendency to asthma Mild Moderate Severe X
170. Weakness after colds or influenza Mild Moderate Severe X
171. Exhaustion - muscular and nervous Mild Moderate Severe X
172. Respiratory disorders (breathing disorders) Mild Moderate Severe X
Female Only Questions 173 to 185 are for Women Only.
173. Very easily fatigued Mild Moderate Severe X
174. Premenstrual tension Mild Moderate Severe X
175. Painful menses (periods are painful) Mild Moderate Severe X
176. Depressed feeling before menstruation Mild Moderate Severe X
177. Menstruation excessive and prolonged Mild Moderate Severe X
178. Painful breasts Mild Moderate Severe X
179. Menstruate too frequently (less than 28 days between periods) Mild Moderate Severe X
180. Vaginal discharge (not normal) Mild Moderate Severe X
181. Hysterectomy/ovaries removed Mild Moderate Severe X
182. Menopausal hot flashes Mild Moderate Severe X
183. Menses scanty or missed Mild Moderate Severe X
184. Acne, worse at menses Mild Moderate Severe X
185. Depression of long standing Mild Moderate Severe X
Male Only Questions 186 to 197 are for Men Only.
186. Prostate trouble Mild Moderate Severe X
187. Urination difficult or dribbling Mild Moderate Severe X
188. Night urination frequent Mild Moderate Severe X
189. Depression Mild Moderate Severe X
190. Pain on inside of legs or heels Mild Moderate Severe X
191. Feeling of incomplete bowel movement Mild Moderate Severe X
192. Lack of energy Mild Moderate Severe X
193. Migrating aches and pains Mild Moderate Severe X
194. Tire too easily Mild Moderate Severe X
195. Avoids activity Mild Moderate Severe X
196. Leg nervousness at night Mild Moderate Severe X
197. Diminished sex drive Mild Moderate Severe X
Please list in order of importance: 1. 2. 3. 4. 5.
Disclaimer. This form is not used for diagnosis. The responses you give are used to correlate possible nutritional deficiencies as suggested by your symptoms in the Symptom Evaluator.
Possible causes will be reported to you along with strategies or substitutions and a nutritional program comprised of what 'I or others have or would have done in similar situations' and based on decades of nutritional research will be provided in a report sent to you.
This document and the responses to it are for educational purposes only and the choice and responsibility of what you do remains yours and yours alone.
This is not medical advice and is no substitute for the services of a medical doctor.
I have read the above disclaimer and accept the personal responsibility it represents. Yes (Required) WARNING: This form will not submit without a check in the box above!
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