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Health Profile Assessment Form

Healthy Profile Assessment Form

1. Your Basic Contact Information

Name
Address
City
Province/State
Postal/Zip Code
Phone
Birth Date
Sex
Height
Weight
If you were referred, who referred you?

2. B COMPLEX

3. HYPOGLYCEMIC TENDENCIES

Emotional on Empty Stomach
Shakiness, Headaches, Relieved by Sweets
Weak Spells, Tiredness Mid-Afternoon
Faintness, Dizziness, Lack of Concentration
Irritable before Breakfast, or if Meal Missed
Intense, Frequent Thirst

4. PROTEIN SUPPLEMENT

5. CALCIUM MAGNESIUM

6. BETA CAROTENE PLUS MIXED CAROTENOIDS

7. VITAMIN C (Full Spectrum)

8. VITAMIN E + SELENIUM

9. JOINT HEALTH

Arthritis – Osteoarthritis
Osteoporosis
Bursitis, Tendonitis

10. ZINC

11. ESSENTIAL FATTY ACIDS

12. BOWEL HEALTH

13. BLOOD SUGAR

Hypoglycemic Tendencies (see Vit. B)
Diabetic Responses

14. INTESTINAL MICROFLORA

15. ALFALFA

16. GARLIC

17. MENTAL HEALTH

Depression
Anxiety
Panic Attacks

18. WOMEN’S HEALTH

Peri / Post Menopausal Symptoms
Option 2

19. MEN’S HEALTH

Prostrate Gland Enlargement
Infertility / Impotency

20. LIVER HEALTH

Coated Tongue
Bad Breath, Bad Taste in Mouth
Occasional Body Odour, Including Feet
Liver Problems

21. CIRCULATORY HEALTH

Poor Memory
Poor Circulation
High Blood Pressure
Muscle Pain

22. ENERGIZER

23. DIGESTIVE AID

24. IMMUNE SYSTEM

25. METABOLIC AID

26. STRESS

All Stress Symptoms
Tension

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