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Listed below are many of the physical and psychological challengs that effect the quality of life of many Americans. Please check the first box for current problems/challenges and the second box for past issues. Please be sure to check only those that pertain to you. For each of the issues you check please give us any addition information you feel comfortable expressing on that particular health issue I.E. when, what type, how often, and what you think. The more information you give, the more accurate we can be in our suggestions.

heart

CurrentPast

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chest pains

CurrentPast

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anemia

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blood vessels

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blood clots

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varicose veins

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phlebitis

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blood pressure

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circulation

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edema

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raynaud's

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triglycerides

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cholesterol

CurrentPast

HDL - LDL

stroke

CurrentPast

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stomach

CurrentPast

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nausea

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hiatal hernia

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ulcers

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abdominal pain

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heartburn

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bloating

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gas

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digestion

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irregularity

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BMs a Day

times a day

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diarrhea

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colitis

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colon

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I.B.S.

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hemorrhoid

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diverticulitis

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Crohn's Disease

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kidneys

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kidney infections

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kidney stones

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blood in urine

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bladder

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bladder infections

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adrenal disorder

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thyroid

CurrentPast

hypo - hyper

eyes

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blurred vision

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cataract

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ears

CurrentPast

internal itchingringing

liver

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hepatitis

CurrentPast

type?

mono

CurrentPast

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cancer

CurrentPast

Where?

tumors

CurrentPast

Where?

abscess

CurrentPast

Where?

warts

CurrentPast

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menal illness

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depression

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insomnia

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nervous ailment

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fatigue

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weakness

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lacking energy

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chronic fatigue

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tired after eating

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pregnant?

CurrentPast

want to be?

breast feeding

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fertility problems

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miscarriage

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P.M.S.

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menstual cramps

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menstrual irregularity

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vaginal yeast infection

CurrentPast

how often?

breast implants

CurrentPast

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reproductive organs

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hysterectomy

CurrentPast

complete?

menopause

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hot flashes

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sex drive

CurrentPast

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prostate

CurrentPast

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incontinence

CurrentPast

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frequent urination

CurrentPast

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arthritis

CurrentPast

type?

osteoporosis

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carpal tunnel synd.

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bone spur

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scoliosis

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joints

CurrentPast

explain

discs

CurrentPast

explain

muscles

CurrentPast

explain

fibromialgia

CurrentPast

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wiplash

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lower back pain

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upper back/neck pain

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numb/tingling extremities

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popping in joints

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bruising

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ridges in fingernails

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muscle cramps

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asthma

CurrentPast

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emphysema

CurrentPast

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allergies

CurrentPast

air food skin medication other

sinus/post nasal dip

CurrentPast

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sinus infection

CurrentPast

how often

candida

CurrentPast

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congestion

CurrentPast

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flu/colds

CurrentPast

how often?

chills/coldness

CurrentPast

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sore throat/strep

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cough/laryngitis

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pnuemonia

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anibiotics

CurrentPast

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acne

CurrentPast

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scalp itch

CurrentPast

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hair loss

CurrentPast

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athlete's foot

CurrentPast

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jock itch

CurrentPast

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eczema/psoriasis

CurrentPast

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sunburn

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insect bites

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hypoglycemia

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diabetes

CurrentPast

in family history

cold extremities

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yawn often

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toxic

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short of breath

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gingivitis/gums

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cold sores

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herpes

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shingles

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V.D.

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H.I.V./A.I.D.S.

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migraines

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headaches

CurrentPast

where on your head do your headaches start?

stress

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muscle tension

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T.M.J.

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dental work

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dizziness

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light headed

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over weight

CurrentPast

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under weight

CurrentPast

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losing weight

CurrentPast

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eating disorder

CurrentPast

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body odor

CurrentPast

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bad breath

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snoring

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gout

CurrentPast

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nose bleed

CurrentPast

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nicotine

CurrentPast

amount?

parasites

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chemical imbalance

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pleurisy

CurrentPast

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M.S./M.D.

CurrentPast

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lupus

CurrentPast

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epilepsy

CurrentPast

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Parkinson's

CurrentPast

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list your cravings

any other comments

what kind, if any of physical activity do you do?

daily intake:

Cans of soda - 8oz. glasses of water Cups of coffee - 8oz. glasses of juice Food Cravings List your medications or perscriptions What is your most important health concern?