ALTERNATIVE HEALTH AND HEALING.
Health is the greatest possession.
Lao Tzu



FREE

Health Questionaire

The following Health Questionaire is a simple, effective tool developed with the you in mind. This tool can be used to determine which protocols are right for you or your family. Your answers are carefully calculated , we will then provide a recommendation with the highest ranking product or system

First Name: .......HAVE YOU BEEN DIAGNOSED WITH
Have you been Diagnosed with Cancer Yes Type  
Have you been Diagnosed with Aids/HIV Yes Type  
Have you been Diagnosed with Heart Dis-ease Yes Type  
Have you been Diagnosed with Diabetes Yes Type  
Have you been Diagnosed with Arthritis Yes Type
Have you been Diagnosed with Fibromyalgia Yes
Have you been Diagnosed with Lupus Yes
Has a family member been Diagnosed with Parkinsons Yes  
Have you been Diagnosed with CFS Yes  
Have you been Diagnosed with Kidney Dis-ease Yes Type  
Have you been Diagnosed with Liver Dis-ease Yes Type  
Have you been Diagnosed with Hep C Yes  
Have you been Diagnosed with MS Multiple Sclerosis Yes  
Have you been Diagnosed with Osteoporosis Yes  
Have you been Diagnosed with Stress Yes  
Have you been Diagnosed with Depression Yes
Have you been Diagnosed with Anxiety Yes
Have you been Diagnosed with Eye Die-ease Yes Type  
Have you been Diagnosed with Asthma Yes  
Have you been Diagnosed with PMS Yes  
Have you been Diagnosed with Allergies Yes Type  
Have you been diagnosed with any OTHER dis-ease not listed above? Yes Type  
 
General..Questionaire....................
1) What is your age?  Years
2) Aproximate Height/Weight  Height  Weight lbs
3) Are you male or female? M F  
4) Do you consider your life stressful? Yes No  
5) Do you smoke? Yes No  
6) Do you have a family history and/or concern with cardiovascular health including stroke or heart attack? Yes No  
7) Is your cholesterol over 200mg/dl? Yes No Don't Know
8) If male, are you concerned with your prostate health? Yes No
9) If female, do you need support maintaining healthy estrogen levels and decreasing PMS symptoms? Yes No
10) Do you suffer from any joint discomfort? Yes No  
11) Do you eat fish 2 or more days per week? Yes No  
12) Are you susceptible to colds and or flu? Yes No  
13) Do you have a family history and/or have concern with developing osteoporosis? Yes No  
14) Are strong bones important to you? Yes No  
15) Do you have concerns with short-term memory loss or an inability to concentrate? Yes No  
16) Would you like to improve the appearance of your hair, skin, and nails? Yes No  
17) Are you interested in reducing the risk of heart disease? Yes No  
18) Do you want to provide your children or grandchildren the nutritional support they need to grow healthy? Yes No N/A
19) If you answered yes to 18: How old are your children, grandchildren 0-12 12-19 N/A
20) Are you concerned with premature aging? Yes No  
21) Do you exercise 3 or more days per week? Yes No  
22) Do you eat 5 servings of fruit and vegetables per day? Yes No  
23) Do you have energy level swings throughout the day? Yes No  
24) Are you overweight? Yes No  
25) Would you like to reduce your body fat? Yes No  
26) Do you find yourself eating fast foods daily? Yes No  
 
More Specific
*** Important
27) Have you been diagnosed with any OTHER dis-ease?***

28) Do you have any pain ?*** Yes No

Where is your Pain
29) Do you have any Nausea ?*** Yes No Don't Know
30) Do you have any Swelling ? *** Yes No Where is your Swelling
31) Do you have any Lumps ? Yes No Where are your Lumps
32) Do you have any Discharge ? *** Yes No Where is the discharge
33) Do you have any Gum Promlems ? *** Yes No Don't Know
34) Do you have any MuscleWeekness ? Yes No Cronnic
35) Do you have any Joint Pain ? Yes No Where is your Joint pain
36) Do you have Anxiety Attacks ? Yes No Don't Know
37) Do you suffer from Stress ? Yes No Don't Know
38) Do you have any Eating Disorders ? Yes No Type
39) Do you have Blood in your Urine ?*** Yes No Don't Know
40) Do you have Blood in your Stool ?*** Yes no Don't Know
41) Are you Constipated ? Yes No Don't Know
42) Are you finding yourself Confussed ? Yes No Don't Know
43) Are you using any Alternative
Therapy ?		 Yes No Eg Gerson, Hoxsey
44) Are you experiencing problems Urinating ? Yes No
45) Are you experiencing Sexual Problems ? Yes No
46) Do you have Diabetes ? *** T1 T2 T3
47) Have you had any Operations ? Yes No Please List
48) Have you had any serious accidents ? Yes No Please List
49) Blood Pressure *** H L N
50) Have you ever been Shot Stabbed or Beaten ? Yes No Please List
51) Are you taking any Medication ? *** Yes No Please List
52) Are you taking any Health Supplements ? *** Yes No

Please List

 
 


Would you like more information on alteranative healing Eg: Rife tools,,,MWO,,,Colloidal Silver, ,Supplements?

Yes
Contact Details:
Name:
E-mail :
Phone Number

Disclaimer

This Health Assessment is not a diagnostic instrument, therefore, the information provided to you should not be used for diagnosis or treatment of any medical condition. This tool cannot take the place of your physician, or other responsible health professional, who should be consulted for the address and/or management of any medical condition. This Health Assessment is an educational instrument that identifies both positive and negative influences upon the health of individuals based upon epidemiology and biostatistics. This Health Assessment does not warrant that any of the information provided to you applies specifically to your individual health situation. We do not recommend, advise, or suggest that anyone use the information as a sole resource for diagnostic or educational purposes

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Disclaimer

This Health Assessment is not a diagnostic instrument, therefore, the information provided to you should not be used for diagnosis or treatment of any medical condition. This tool cannot take the place of your physician, or other responsible health professional, who should be consulted for the address and/or management of any medical condition. This Health Assessment is an educational instrument that identifies both positive and negative influences upon the health of individuals based upon epidemiology and biostatistics. This Health Assessment does not warrant that any of the information provided to you applies specifically to your individual health situation. We do not recommend, advise, or suggest that anyone use the information as a sole resource for diagnostic or educational purposes.

Despite claims made to the contrary, This Health Assessment is not a predictor of an individual's actual medical and health future, or eventual cause of death. Rather, this tool provides a summary report based upon the odds, or likelihood of certain health risks occurring in a group of people with certain, common characteristics. This Health Assessment serves to raise consciousness and prompt the individual to consider their life activities and the opportunities available to improve health status over time.