FREE Health Self-Survey

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Greetings and welcome!

Good health is not a mundane, one-size-fits-all state of being. Rather, effective health care requires innovation, which often includes attention to lifestyle and nutrition. This free survey is for your own research purposes. Each of the following sections contains questions focused on nutritional conditions that may be affecting your health and personal well being.

Please complete the survey using either a printout or a separate piece of paper on which to write your responses. Answer each question by writing down the number that best describes your situation, then total your score for each section, and submit your answers in the message window at the bottom. Upon submission, a professional health care advocate will reply to you with tips and suggestions that target your situation. All details are held in strict confidence and will be used only to evaluate and reply to your survey. There is no charge for this service.

Section A
For each question in this section, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you eat fast food?
2. ____ How often do you eat process food? (e.g. frozen dinners, canned foods)
3. ____ How often do you eat cooked foods?
4. ____ How often do you drink carbonated beverages?
5. ____ How often do you drink caffeinated drinks? (e.g. coffee, cola)
6. ____ How often do you drink alcohol?

____ = Total Section A

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Section B
For each question in this section, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you experience bloating?
2. ____ How often do you feel sleepy after eating?
3. ____ How often do you have uncomfortable reactions after eating?
4. ____ How often do you eat processed and/or cooked foods?
5. ____ How often do you have diarrhea after eating?
6. ____ How often do you feel flush (feel hot) after eating?
7. ____ How often do you have difficulty breathing after eating?
8. ____ How often do you see your food pass through undigested?
9. ____ How often do you get indigestion after eating?
10. ____ How often do you have excess stomach acid?
11. ____ How often do you have heartburn?
12. ____ How often do you have trouble sleeping?
13. ____ How often do you experience weakness or faintness between meals?
14. ____ How often do you have difficulty gaining or losing weight?
15. ____ How often do you have pain in the upper right quadrant of the stomach?

____ = Total Section B

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Section C
For each question in this section, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you have a low level of energy?
2. ____ How often do you get depressed?
3. ____ How often do you have trouble with your short-term memory?
4. ____ How often do you have low energy after eating?
5. ____ How often do you have low stamina?
6. ____ How often do you experience excessive fatigue during workouts?
7. ____ How often do you experience heartburn after eating?
8. ____ How often do you have sugar cravings?
9. ____ How often do you feel tired after a full night of sleep?
10. ____ How often do you feel too full after eating?
11. ____ How often do you have cravings for fatty foods?
12. ____ How often do you eat unbalanced meals? (e.g. meats vs. vegetables)
13. ____ How often do you feel exhausted after your usual daily activities?

____ = Total Section C

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Section D
For each of the following questions 1 - 10, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you have hemorrhoids?
2. ____ How often do you get bloody noses?
3. ____ How often do you have bleeding gums?
4. ____ How often do you smoke?
5. ____ How often do you get exposed to second-hand smoke?
6. ____ How often do you get exposed to smog?
7. ____ How often do you experience excessive nervousness?
8. ____ How often do you work around computers, electrical appliances, etc.?
9. ____ How often do you get colds?
10. ____ How often do you have heartburn?
For each of the following questions 11 - 15, write down the number that best describes your situation:
0 = No, 2 = Yes
11. ____ Do you have age spots?
12. ____ Do you have deteriorating eye sight?
13. ____ Do you have excessive wrinkling of skin?
14. ____ Do you have varicose veins?
15. ____ Do you bruise easily?

____ = Total Section D

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Section E
For each of the following questions 1 - 8, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you have gas, flatulence, bloating belching or burping?
2. ____ How often do you have diarrhea?
3. ____ How often do you get sick?
4. ____ How often do you have cold sores?
5. ____ How often do you experience yeast infections?
6. ____ How often do you consume alcohol or carbonated beverages?
7. ____ How often do you suffer from migraine headaches?
8. ____ How often do you consume dairy products?
For each of the following questions 9 - 13, write down the number that best describes your situation:
0 = No, 2 = Yes
9. ____ Do you have bad breath?
10. ____ Do you have house pets?
11. ____ Do you suffer from hemorrhoids?
12. ____ Have you taken antibiotics over the last 90 days?
13. ____ Have you traveled outside the U.S. within the last 90 days?

____ = Total Section E

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Section F
For each of the following questions 1 - 8, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you get leg cramps?
2. ____ How often do you have muscle pain?
3. ____ How often do you have deep aching in your bones?
4. ____ How often do you have joint pain in your legs, arms, hands, or feet?
5. ____ How often do you have trouble becoming mobile in the morning?
6. ____ How often do your joints feel inflamed?
7. ____ How often do you have disc problems?
8.____ How often do you have arthritis?
For each of the following questions 9 - 10, write down the number that best describes your situation:
0 = No, 2 = Yes
9. ____ Are your joints calcified or misshapen?
10. ____ Do you have a decreased range of motion in your joints?

____ = Total Section F

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Section G
For each of the following questions 1 - 8, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you get exposed to smog?
2. ____ How often do you experience nervous tension?
3. ____ How often do you have trouble sleeping?
4. ____ How often do you experience sexual malfunction?
5. ____ How often do you feel exhausted?
6. ____ How often do you experience mood swings?
For each of the following questions 7 - 12, write down the number that best describes your situation:
0 = No, 2 = Yes
7. ____ Do you experience arrhythmias? (i.e. irregular heartbeat)
8. ____ Do you have high blood sugar
9. ____ Do you have mercury fillings in your teeth?
10. ____ Do you use an anti-perspirant that contains aluminum?
11. ____ Do you have high cholesterol? (i.e. a count over 200)
12. ____ Does your family have a history of heart disease?

____ = Total Section G

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Section H
For each of the following questions 1 - 8, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you experience sexual dysfunction?
2. ____ How often do you have difficulty with menstrual regulation? (women only)
3. ____ How often do you experience fatigue?
4.____ How often do you experience “hot flashes”? (women only)
5. ____ How often do you have mood swings?
6. ____ How often do you lose your libido, your sexual drive?
7. ____ How often do you experience short-term memory loss?
8. ____ How often do you experience loss of energy?
For each of the following questions 9- 13, write down the number that best describes your situation:
0 = No, 2 = Yes
9. ____ Do you have premature graying of your hair?
10. ____ Do you have loss of skin elasticity?
11. ____ Are you experiencing muscle loss and fat increase?
12. ____ Do you have difficulty recovering from minor injuries?

____ = Total Section H

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Section I
For each of the following questions 1 - 3, write down the number that best describes your situation:
0 = Never, 1 = Sometimes, 2 = Often
1. ____ How often do you drink and drive?
2. ____ How often do you experience high stress?
3.____ How often do you experience frustration and anger?
For each of the following questions 4 - 8, write down the number that best describes your situation:
0 = No, 2 = Yes
4. ____ Do you tend to drive your car aggressively?
5. ____ Do you work, or have you worked, in a toxic environment?
6. ____ Do you spend eight or more hours a day sitting at a desk or in a car?
7. ____ Do you smoke?
8. ____ Do you live in a major urban or suburban area?

____ = Total Section I

Congratulations on completing the survey! Please provide your name, email address and section totals below in the following format: A = , B =, C =, etc.. Click "Send Email" button to submit, and a health care advocate will reply to you with health tips and suggestions based on your situation/ All personal information is held in strict confidence. There is no charge for this service.

Disclaimer: All statements above and on all accompanying web pages are for educational purposes only and are not to be misconstrued as medical cure, diagnosis, treatment, disease prevention or health assessment. None of this information has been evaluated by the Food and Drug Administration (FDA).

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