* Required

Member's Name: *

Member's Phone: *

Member's Email: *

Street Address:

City, State, Zip:

Today's Date:

Age: *

Sex: Select One Male Female *

Height: *

Weight: *

Wrist Size (inches): *

Exercise Level: Select One Light Moderate Heavy

Nutritional Advisor: *

Advisor Phone: *

Advisor email: *

---------------------------------------------------------------------------------

Section 1:

Check off how many apply and select a TOTAL below:

1. Do you have heart palpitations?

2. Do you have an enlarged heart?

3. Do you have a diastolic blood pressure over 90?

4. Do you hurt all over, but can't pinpoint an area?

5. Do you suffer from forgetfullness?

6. Do you have vague fears about many things?

7. Do you feel that others are against you?

8. Are you abnormally tired?

9. Are you often confused about life and your purpose in it?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9

---------------------------------------------------------------------------------

Section 2:

Check off how many apply and select a TOTAL below:

10. Do you suffer from eczema?

11. Have you been diagnosed as having atherosclerosis?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 3 :

Check off how many apply and select a TOTAL below:

12. Do you have breathlessness on slight exertion?

13. Do you have breathlessness on lying down?

14. Do you have a nagging cough?

15. Do your ankles swell late in the day?

16. Do you urinate more than twice during the night?

* How Many Apply To You ? Select One 0 1 2 3 4 5

---------------------------------------------------------------------------------

Section 4:

Check off how many apply and select a TOTAL below:

17. Do you have alcohol intolerance?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 5:

Check off how many apply and select a TOTAL below:

18. Do you feel depressed?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 6:

Check off how many apply and select a TOTAL below:

19. Do you often suffer from dizziness?

20. Do you often suffer from nausea?

21. Do you often feel confused?

22. Do you have, or have you had kidney stones?

23. Do you have edema (swelling of hands, feet, ankles)?

24. Have you ever observed a greenish tint to your urine?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6

---------------------------------------------------------------------------------

Section 7:

Check off how many apply and select a TOTAL below:

25. Do you have little pink spots on your skin?

26. Do you have ruptured blood vessels in either eye?

27. Do you often feel confused?

28. Do you have inflammed gums?

29. Is your hair falling out abnormally?

30. Do your gums bleed when you brush your teeth?

31. Do you have cartilage problems?

32. Do you have more than two colds per year?

33. Do you smoke more than 3 cigarettes per day?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9

---------------------------------------------------------------------------------

Section 8:

Check off how many apply and select a TOTAL below:

34. Do you consider yourself "weak muscled"?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 9:

Check off how many apply and select a TOTAL below:

35. Do you have muscular type problems such as
swelling or wasting away?

36. Do you suffer from angina pains?

37. Have you had a heart attack?

38. Male: Is your sex drive low?

* How Many Apply To You ? Select One 0 1 2 3 4

---------------------------------------------------------------------------------

Section 10:

Check off how many apply and select a TOTAL below:

39. Do you have frequent gas?

40. Are you frequently bloated?

41. Are your frequently constipated?

42. Do you have frequent indigestion?

43. Do you have alternating diarrhea and constipation?

44. Do you frequently suffer from diarrhea?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6

---------------------------------------------------------------------------------

Section 11:

Check off how many apply and select a TOTAL below:

45. Do you accumulate fluids in the extremities?

46. Do you have cateracts?

47. Do you think, or know, that you have low hormone levels?

48. Do you have low resistance to disease?

49. Do you feel overall weakness?

* How Many Apply To You ? Select One 0 1 2 3 4 5

---------------------------------------------------------------------------------

Section 12:

Check off how many apply and select a TOTAL below:

50. Do your wounds heal very slowly?

51. Have you lost part of your sense of smell?

52. Have you lost part of your sense of taste?

53. Do you have acne?

54. Male: Do you suffer from prostatitis?

* How Many Apply To You ? Select One 0 1 2 3 4 5

---------------------------------------------------------------------------------

Section 13:

Check off how many apply and select a TOTAL below:

55. Do you suffer from dehydration (dry tongue, shrunken, loose skin)?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 14:

Check off how many apply and select a TOTAL below:

56. Do you gain weight easily?

57. Do you tend to have cold hands and feet?

58. Do you prefer warm to cool climate?

59. Is your hair scanty, dry, brittle and lusterless?

60. Are your bowel movements usually less than once daily?

61. Do you have diminishing libido (sex drive)?

62. Does your heart beat rapidly on slight exertion?

63. Do you tolerate heat poorly?

64. When holding your hands out with fingers straight,
do fingers tremble?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9

---------------------------------------------------------------------------------

Section 15:

Check off how many apply and select a TOTAL below:

65. Female: Do you have menstrual discomfort?

66. Female: Are your periods regular, profuse, but painless?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 16:

Check off how many apply and select a TOTAL below:

67. Do you have chronic headaches?

68. Do you suddenly feel dizzy?

69. Do you feel lightheaded when getting up out of
a lying or sitting position?

70. Does your heart beat fast upon exertion?

71. Has your doctor diagnosed you as arthritic?

72. Has your doctor diagnosed you as hypoglycemic?

73. Do you occasionally have a burning sensation
of hands and/or feet?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7

---------------------------------------------------------------------------------

Section 17:

Check off how many apply and select a TOTAL below:

74. Do you have poor bone development?

75. Have you had rickets (bowlegs, knock-knees, bone enlargement)?

76. Has your doctor diagnosed osteomalacia (softening of bones)?

77. Has your doctor diagnosed arthritis?

78. Do you or did you have an abnormal number of cavities?

* How Many Apply To You ? Select One 0 1 2 3 4 5

---------------------------------------------------------------------------------

Section 18:

Check off how many apply and select a TOTAL below:

79. Do you suffer from vitiligo (white patches on skin)?

80. Do you have excema off and on?

81. Have you been diagnosed as having lupus erythematosis?

82. Have you been diagnosed as having acieroderma?

83. Is your sex drive low?

* How Many Apply To You ? Select One 0 1 2 3 4 5

---------------------------------------------------------------------------------

Section 19:

Check off how many apply and select a TOTAL below:

84. Do you have short, heavy-muscled physique?

85. Do you have much body hair?

86. Do you have high blood pressure?

87. Do you tend to have a rapid pulse?

88. Do you have more than usual neck, head, shoulder stress?

89. Do you have low blood pressure?

90. Do you suffer from low blood sugar or hypoglycemia?

91. Have you ever had convulsions, blackouts or coma?

92. Do you have an inferiority complex?

93. Do you tend to be negative?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9 10

---------------------------------------------------------------------------------

Section 20:

Check off how many apply and select a TOTAL below:

94. Do you become short of breath easily?

95. Do you find it difficult to be satisfied with a deep breath?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 21:

Check off how many apply and select a TOTAL below:

96. Do you have high blood pressure?

97. Do you have a problem losing weight?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 22:

Check off how many apply and select a TOTAL below:

98. Do you catch cold easily?

99. Do you have a predisposition to infections of the throat and lungs?

100. Do you have frequent infections of the bladder or urinary tract?

101. Do you suffer from sinusitis?

102. Do you often have abscesses in the ears?

103. Do you see poorly in dim light?

104. Do you have rough, dry, scaly, skin?

105. Do your eyelids become swollen and pus laden?

106. Female: Difficulty in getting pregnant?

107. Female: Have you had a spontaneous abortion?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9 10

---------------------------------------------------------------------------------

Section 23:

Check off how many apply and select a TOTAL below:

108. Do you suffer from chronic inflammation of the skin?

109. Have you lost your appetite?

110. Do you have canker sores in the mouth?

111. Do your hands and/or feet often feel like they are hot?

112. Have you ever been diagnosed as a schizophrenic?

113. Do you feel like your hands and/or feet go numb?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6

---------------------------------------------------------------------------------

Section 24:

Check off how many apply and select a TOTAL below:

114. Do you have indigestion 2-3 hours after eating?

115. Do you have a heavy, full, loggy feeling after eating a large meal?

116. Do you have more than usual upper and lower intestinal gas?

117. Have you lost your taste or craving for meat?

118. Have you been treated for long periods of time for
anemia without making much progress?

119. Do you have a sour stomach?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6

---------------------------------------------------------------------------------

Section 25:

Check off how many apply and select a TOTAL below:

120. Do you have tremor of hands or head?

121. Do you see double?

122. Do you have slurred speech?

123. Are you irritable and impatient?

124. Do you have loss of stamina while working physically?

125. Do you fall asleep easily during the day?

126. Are you emotionally unstable (lose your temper easily, etc.)?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7

---------------------------------------------------------------------------------

Section 26:

Check off how many apply and select a TOTAL below:

127. Do you have swelling of the ankles and hands?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 27:

Check off how many apply and select a TOTAL below:

128. Do you have chronically pale skin?

129. Do you have shortness of breath?

130. Do you have a poor appetite?

131. Do you have a sensation of spots before your eyes?

132. Are the palms of your hands pale?

133. Do your fingernails appear very light in color?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6

---------------------------------------------------------------------------------

Section 28:

Check off how many apply and select a TOTAL below:

134. Have you ever been diagnosed as having cholesterol in blood?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 29:

Check off how many apply and select a TOTAL below:

135. Have you ever had macrocytic anemia?

136. Do you have a history of cleft palate?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 30:

Check off how many apply and select a TOTAL below:

137. Do you have diabetic tendencies?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 31:

Check off how many apply and select a TOTAL below:

138. Do you have more than the usual number of cavities?

139. Do you look older than you are?

140. Is your heartbeat irregular?

141. Are you susceptible to infections?

* How Many Apply To You ? Select One 0 1 2 3 4

---------------------------------------------------------------------------------

Section 32:

Check off how many apply and select a TOTAL below:

142. Do you feel as if your nerves and muscles are irritable?

143. Do you suffer from convulsions or seizures?

144. Do you have dimmed vision?

145. Are your teeth sensitive?

146. Do you have loose teeth?

147. Are you constantly cold?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6

---------------------------------------------------------------------------------

Section 33:

Check off how many apply and select a TOTAL below:

148. Is your tongue often sore?

149. Do you have skin inflammations often?

150. Do you suffer from insomnia?

151. Do you have a poor appetite?

152. Are you frequently nauseated?

* How Many Apply To You ? Select One 0 1 2 3 4 5

---------------------------------------------------------------------------------

Section 34:

Check off how many apply and select a TOTAL below:

153. Do you have stunted body growth?

154. Do you have an abdominal "apron" of fat?

155. Do you have feelings of inadequacy?

156. Do you have headaches inside the middle of your head?

157. Do you have eye problems?

158. Are you tall and very thin?

159. Do you have problems mobilizing energy?

160. Do you have an easily changeable temperament?

161. Are you moody and sentimental?

162. Do you have long hands and feet?

163. Do your feelings dominate over logic?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9 10 11

---------------------------------------------------------------------------------

Section 35:

Check off how many apply and select a TOTAL below:

164. Are your eyes sensitive to light?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 36:

Check off how many apply and select a TOTAL below:

165. Is your tongue sore?

166. Have you noticed your hands and/or feet tingle?

167. Do you feel you have lost your incentive in life?

168. Do you occasionally stammer?

169. Do you have jerking of limbs?

* How Many Apply To You ? Select One 0 1 2 3 4 5

---------------------------------------------------------------------------------

Section 37:

Check off how many apply and select a TOTAL below:

170. Do you have an irregular heart beat?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 38:

Check off how many apply and select a TOTAL below:

171. Are you taller than most people your sex?

172. Is your fifth finger particularly short?

173. Do you have sparse hair (especially pubic)?

174. Do you have tapered fingers?

175. Are you thin-breasted (female) or have small external genital (male)?

176. Do you have soft fingernails?

177. Do you have voice quality of opposite sex?

178. Do you have reduced physical and emotional stamina?

179. Do you perspire easily?

180. Are your actions quicker than others?

181. Did your sex characteristics develop early?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9 10 11

---------------------------------------------------------------------------------

Section 39:

Check off how many apply and select a TOTAL below:

182. Are you hyperirritable, nervous?

183. Do you have "nervous tics or twitches"?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 40:

Check off how many apply and select a TOTAL below:

184. Do you have weak hair and nails?

185. Do you have fungus infection of the nails?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 41:

Check off how many apply and select a TOTAL below:

186. Do you often have leg cramps?

187. Are your teeth prone to decay?

188. Are your teeth crowded, with poor placement in the mouth?

* How Many Apply To You ? Select One 0 1 2 3

---------------------------------------------------------------------------------

Section 42:

Check off how many apply and select a TOTAL below:

189. Do you have cracks or sores in the corner of your mouth?

190. Does your tongue have a red-purple color?

191. Is your tongue shiny?

192. Do you often have a sensation of sand in your eyelids?

193. Do your eyes get tired easily?

194. Do your eyes burn and itch often?

195. Do you have a lot of red lines in the whites of your eyes?

196. Do you have, or have you had cataracts?

197. Do you have an abnormal amount of oil
in the skin near the corner of your nose?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9

---------------------------------------------------------------------------------

Section 43:

Check off how many apply and select a TOTAL below:

198. Are you fatigued mentally?

199. Are you fatigued physically?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 44:

Check off how many apply and select a TOTAL below:

200. Do you suffer from cancer?

201. Do you have or your children have birth defects?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 45:

Check off how many apply and select a TOTAL below:

202. Does your blood clot slowly, if you should cut yourself?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 46:

Check off how many apply and select a TOTAL below:

203. Is your hair dry?

204. Do you have brittle nails?

205. Do you feel your mental reaction time is slow?

206. Do you have a golter, or have you had one?

207. Do you have a stuffy nose?

208. Do you have recurrent styes?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6

---------------------------------------------------------------------------------

Section 47:

Check off how many apply and select a TOTAL below:

209. Do you have a chronic cough?

210. Have you had several chest colds in the past year?

* How Many Apply To You ? Select One 0 1 2

---------------------------------------------------------------------------------

Section 48:

Check off how many apply and select a TOTAL below:

211. Are you prone to athletic-type injuries, strained knees?

212. Is your muscular coordination poor?

213. Have you been diagnosed as myasthenia gravis
or multiple sclerosis?

214. Do you have bone deformities?

* How Many Apply To You ? Select One 0 1 2 3 4

---------------------------------------------------------------------------------

Section 49:

Check off how many apply and select a TOTAL below:

215. Do you have pyorrhea?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 50:

Check off how many apply and select a TOTAL below:

216. Do you suffer from the heat?

217. Do you overbreathe (hyperventilate)?

218. Are you on a low salt diet?

* How Many Apply To You ? Select One 0 1 2 3

---------------------------------------------------------------------------------

Section 51:

Check off how many apply and select a TOTAL below:

219. Do you suffer from allergies?

* How Many Apply To You ? Select One 0 1

---------------------------------------------------------------------------------

Section 52:

Check off how many apply and select a TOTAL below:

220. Do you have a big appetite?

221. Do you have constant, intese thirst?

222. Do you urinate more than 2 quarts daily?

223. Does your breath sometimes smell sweet or like acetone?

224. Do you sometimes have peculiar, unaccountable sensations
in hands or feet (tingling, burning, sharp jabs, numbness, etc.)?

225. Is your vision failing rather rapidly?

226. Does your urine contain sugar?

227. Do your cuts and abrasions heal slowly?

228. Are you excessively fatigued?

229. Does even the thought of walking across the room make you feel tired?

230. Are you moody with marked ups and downs?

231. Do you have vague, unrelated complaints which can be temporarily
improved by eating only to return with a vengeance is an short time?

232. Do you have cold sweats of the hands even when warm or excited?

233. Have you ever fainted, blacked out, or had a convulsion?

* How Many Apply To You ? Select One 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

---------------------------------------------------------------------------------

SUPPLEMENTATION INFORMATION:

Indicate which supplements you are currently taking, how long
& quantity taken DAILY

---------------------------------------------------------------------------------

---------------------------------------------------------------------------------