Name: ______________________________ Age: _______ Sex: _______ Date:______________
Part 1
Please list the 5 major health concerns in your order of importance:
1. _______________________________________________________________________________2. _______________________________________________________________________________3. _______________________________________________________________________________4. _______________________________________________________________________________5. _______________________________________________________________________________ Please circle the appropriate number "0 - 3" on all questions below.
0 as the least/never to 3 as the most/always.

Category I
Category V
Feeling that bowels do not empty completely Lower abdominal pain relief by passing stool or gas Lower bowel gas and or bloating several hours Bitter metallic taste in mouth, especially in the am Coated tongue of "fuzzy" debris on tongue Stool color alternates from clay colored to normal Category II
Category VI
Depend on coffee to keep yourself going or started Difficulty digesting fruits and vegetables: Category III
Stomach pain, burning, or aching 1 - 4 hours after eating Heartburn when lying down or bending forward Category VII
Temporary relief from antacids, food, milk, carbonated Category IV
Indigestion and fullness lasts 2-4 hours after eating Waist girth is equal or larger than hip girth Pain, tenderness, soureness on left side under rib cage Stool undigested, foul smelling, mucous-like, greasy,or Category VIII
Category XIV (Males Only)
Category XV ( Males Only)
Decrease in spontaneous morning erections Category IX
Difficuly in maintaining mornign erections Wake up tired even after 6 or more hours of sleep Excessive perspiration or perspiration with little Increase in fat distributin around chest and hips Category X
Require excessive amounts of sleep to function properly Category XVI (Menstruating Females Only
Increase in weight gain even with low-calorie diet Extended menstrual cycle, greater than 32 days Shortened menses, less that every 24 days Morning headaches that wear off as the day progresses Thinning of hair on scalp, face or genitals or excessive Category XI
Category XVII (Menopausal Females Only)
Since menopause, do you have uterine bleeing? Category XII
Menstrual disorders of lack of menstruation Increased ability to eat sugars without symptoms Category XIII
Increased vaginal pain, dryness or itching How many alcholic beverages do you consume per week? _____________________________________ How many caffeinated beverages do you consume per day?_____________________________________ How many times do you eat out per week? _________________________________________________ How many times a week do you eat raw nuts or seeds? _______________________________________ How many times a week do you eat fish ____________________________________________________ How many times a week do you workout? ___________________________________________________ List the three worst foods you eat during the average week: ____________, _______________, ___________________ List the three healthiest foods you eat during the average week: ___________________, ______________, ___________ If yes, how many times a day: ________________ Rate your stress levels on a scale of 1 - 10 during the average week: ____________________________ Please list any natural supplements you currently take and for what conditions: ______________
____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Please list any medications you currently take and for what conditions: _____________________
___________________________________________________________________________________________________ ____________________________________________________________________________________________________ Please circle any of the following medication's you have been on or are currently taking that are not mentioned above
Acetylcholine Receptor Antagonist - Antimusearinic Agents Atropine, Ipratopium, Scopolamine, Tiotropium Acetylcholine Receptor Antagonist - Genlionic Blockers Mecamylamine, Hexameethonium, Nicotine (high doses), Trimethaphan Acetylcholinesterase Reactivators Pralidoxime Acetylcholine Receptor Antagonist - Neuromuscular Blockers Atracurium, Cisatracurium, Doxacurium, Metocurine, Mivacurium, Pancuronium, Rocuronium, Uccinylcholine, Tubocurarine, Vecuronium, Hemicholine Agonist Modulator of GABA Receptor (benzodiazpines) Xanax, Lexotanil, Lexotan, Librium, Klonopin, Valilum, ProSon, Rohypnol, Dalmane, Ativan, Loramet, Sedoxil, Dormicum, Megadon, Serax, Restoril, Halcion Agonist Modulator of GABA Receptors (nonbenzodiazpines) Ambien, Sonata, Lunest, Imovane Cholinesterase Inhibitors (irreversible) Echotiophate, Isoflurophate, Organophosphate Insecticides, Organophosphate- Cholinesterase Inhibitors (reversible) Donepezil, Galatamine, Rivastigmine, Tacine, THC, Erophonium, Neostigmine, Phystigimine, Pyridostigmine, Carbamate Insecticides Dopamine Reuptake Inhibitors Wellbutrin (Bupropion) Dopamine Receptor Agonists Mirapex, Sifrol, Requip D2 Dopamine Receptor Blockers (antipsychotics) Thorazine, Prolixin, Trilafon, Compazine, Mellaril, Stelazine, Vesprin, Nozinan, Depixol, Navane, Luanxol, Clopixol, Acuphase, Haldol, Orap, Clozaril, Zyprexa, Zydis,Seroquel, Geodon, Solian, Invega, Abilify GABA Antagonist Competitive Binder Flumazenil Monoamine Oxidase Inhibitor (MAOI) Marplan, Auroix, Maneric, Moclodura, Nardil, Adlegiine, Elepryl, Azilect, Marsilid, Iprozid, Ipronid, Noradrenergic and Specific Sertonergic Antidepressants (NaSSaa) Remeron, Zispin, Avanza, Norset, Remergil, Axit Selective Serotonin Reuptake Inhibitor Paxil, Zoloft, Prozac, Celexa, Lexapro, Luvox, Cipramil, Emocal, Serpam, Seropram, Cipralex Esteria, Fontex, Seromex, Seronil, Sarafem, Fluctin, Faverin, Seroxat, Aropax, Deroxat, Rexetin, Xentor, Paroxat, Lustral, Serlain Selective Serotonin Reuptake Enhancers Stablon, Coaxil, Tatinol Serotonin - Norepinephrine Reuptake Inhibitors (SNRIs) Effexor, Pristiq, Meridia, Serzone, Dalcipran, Despramine, Duloxetine Tricylic Antidepressants (TCAs) Elavil, Endep, Tryptanol, Trepiline, Asendin, Asendis, Defanyl, Demolox, Moxadil, Anafranil, Norpramin, Pertofrane, Prothiadin, Thanden, Adapin, Sinequan, Trofranil, Janamine, Gamanil, Aventyl, Pamelor, Opipramol, Vivactil,


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