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Free Health Analysis

Copy this Health Questionnaire to Word Perfect and e-mail it to us or you can send it by post.

We will send you a free confidential computerized health analysis and chemistry report.

It will contain a supplementation schedule and a dietary and exercise recommendation.


Patient Symptom History

PHONE NUMBER:____________________________SEX:_____AGE:_____

*Antacids *Chemotherapy *Hormones *Relaxants/Sleeping pills
*Antibiotics/Antifungals *Cortisone Anti-inflammatories *Laxatives *Recreational Drugs (Specify)
*Antidepressants *Diuretics *Lithium *Ulcer Medications
*Antidiabetic/Insulin *Heart Medications *Oral *Aspirin or Tylenol
*High Blood Pressure *Thyroid *Contraceptives *Other (Specify)

*Alcohol *Distilled Water *Milk Products
*Candy or Refined Sugar *Fluoridated/Chlorinated Water *Refined (white) Flour
*Carbonated Beverages *Frequent Fast Food Restaurants *Salt Food Without Tasting
*Chemical Exposure *Luncheon Meat *Under Excessive Stress
*Cigarettes or Exposure to *Margarine * Sweeteners
*Coffee *Tea *Tobacco (chewing)
*Vitamins & Minerals (Specify Below)

DIRECTIONS : Please read each description and fill in the number that best describes the frequency of your symptoms
within the past year. If you do not understand a symptom, put a "?" before the symptom's number.

When done add each Section and put the total in the Total box.



Leave Blank if symptoms Never occur
Put a 1 if symptoms are Mild (Occurs once a month or less)
Put a 2 if symptoms are Moderate (Occurs several times monthly)
Put a 3 if symptoms are Severe (Aware of it almost constantly)

IMPORTANT - list your five mayor health concerns in order of importance and/or any medications you are taking.

1._______________________________________ 4. ______________________________________
2._______________________________________ 5. ______________________________________
How many Dental Amalgam Silver fillings do you have?_________________________________________

Do you have any Root Canals?___________ If yes, how many?_____Crowns?________Bridges?________

_____A.01. History of constipation?
_____A.02. Bad breath/halitosis?
_____A.03. Loss of taste for meat?
_____A.04. Belching shortly after meals?
_____A.05. Bloating or gas shortly after meals?
____Total Section A

_____B.01. Burning or gnawing stomach pain?
_____B.02. Heartburn or indigestion after meals?
_____B.03. Stomach pain from stress and/or spicy foods?
_____B.04. Told you have Ulcers?
_____B.05. Use antacids or aspirin?
_____B.06. Use milk or carbonated drinks to relieve stomach pain?
_____Total Section B

_____C.01. Remnants of food or fibers in stools?
_____C.02. Nausea or diarrhea?
_____C.03. Mucus in stools?
_____C.04. Pass gas frequently?
_____Total Section C

_____D.01. Pain or discomfort in abdomen area?
_____D.02. Have allergies?
_____D.03. Self or Family history of autoimmune disease?
_____D.04. Drink alcohol?
_____D.05. Drink milk or eat dairy products?
_____D.06. Often have constipation or diarrhea?
_____D.07. Frequently have gas?
_____Total Section D

_____E.01. Coated or fuzzy debris on tongue?
_____E.02. Bowel movements painful or difficult?
_____E.03. Irritable bowel or colitis?
_____E.04. Have bad breath?
_____ Total Section E

_____F.01. Burning or itching anus?
_____F.02. Frequently get skin eruptions or bumps?
_____F.03. History of yeast infections, antibiotic use?
_____F.04. Use or have used estrogen compounds?
_____F.05. Have intestinal pain for no apparent reason?
_____F.06. Have diarrhea?
_____F.07. Have allergies or sensitivities?
_____F.08. Get sick often or stay sick?
_____F.09. Feel tired all the time?
_____Total Section F

_____G.01. Pain or discomfort on right side under ribcage?
_____G.02. Blurred vision?
_____G.03. Intolerance to greasy foods?
_____G.04. Eat fast food?
_____G.05. Tightness or pain between shoulder blades?
_____G.06. Light-colored or foul smelling stools?
_____G.07. Feel nauseous or queasy after eating fatty foods?
_____G.08. Drink coffee?
_____G.09. Dry skin, itchy or peeling feet?
_____G.10. Retaining water?
_____G.11. Gag easily?
_____G.12. Sour or metallic taste in mouth?
_____Total Section G

_____H.01. Feet burn?
_____H.02. Noises in head or ringing in the ears?
_____H.03. Strong light irritates eyes?
_____H.04. Drink alcohol?
_____H.05. Sensitive to fumes, smoke, smells, or chemicals?
_____H.06. Thick stringy mucus or swollen lymph nodes?
_____H.07. Have allergies?
_____H.08. Eat luncheon meat?
_____H.09. Bronzing of skin or brown spots?
_____Total Section H

_____I.01. Head congestion or sinus fullness?
_____I.02. Frequent sneezing?
_____I.03. Eyes and nose watery, swollen or puffy?
_____I.04. Nightmare-like dreams?
_____I.05. Dark circles under eyes?
_____I.06. Certain foods cause distress (dairy, corn, wheat)?
_____I.07. Sensitive to fumes, smoke or chemicals?
_____I.08. Thick mucus or swollen lymph nodes?
_____I.09. Chronic sinus infections?
_____Total Section I

_____J.01. Crave sweets or coffee in afternoon or mid-morning?
_____J.02. Hungry between meals or excessive appetite?
_____J.03. Irritable before meals or if meals delayed?
_____J.04. Get shaky or light-headed if meals delayed?
_____J.05. Wake in the night and can't go back to sleep?
_____J.06. Problems with memory in mid-morning or after noon?
_____J.07. Eat sweets, refined foods, or fast foods?
_____Total Section J

_____K.01. Family history of diabetes?
_____K.02. Excessive thirst?
_____K.03. Excessive urination?
_____K.04. Fasting glucose greater than 120 mg/dl?
_____K.05. Overweight by 50 or more pounds?
_____Total Section K

_____L.01. Difficulty maintaining chiropractic adjustments?
_____L.02. Crave salt?
_____L.03. Low blood pressure?
_____L.04. Weakness after colds or slow recovery?
_____L.05. Headaches in afternoon?
_____L.06. Muscular or nervous exhaustion?
_____L.07. Chronic fatigue or slow starter in the morning?
_____L.08. Have allergies or sensitivities?
_____Total Section L

_____M.01. Have anxiety?
_____M.02. Problems sleeping or insomnia?
_____M.03. Crave sweets or coffee in the afternoon or mid-morning?
_____M.04. Get shaky or light-headed if meals delayed?
_____M.05. Retain water?
_____M.06. Are under a lot of stress?
_____M.07. Feel tired or sleepy in afternoon?
_____M.08. Eat refined flour products, sugar or drink coffee?
_____Total Section M

_____N.01. Hair and skin dry but not coarse?
_____N.02. Weight gain around hips and waist?
_____N.03. Sex drive reduced or absent?
_____N.04. Impotence or decrease in size of testes (males).
_____N.05. Infertile or decrease in size of breasts (females).
_____N.06. Abnormal thirst?
_____N.07. Lack of menstruation (females)?
_____Total Section N

_____O.01. Feel worse after chiropractic adjustment?
_____O.02. Forgetful, mental sluggishness, or reduced initiative?
_____O.03. Skin coarse and dry?
_____O.04. Cold hands and feet?
_____O.05. Frequent constipation?
_____O.06. Headaches upon awakening?
_____O.07. Gain weight easily?
_____O.08. Cry easily, worse with change in season?
_____O.09. Hair thin or falling out?
_____O.10. Feel depressed?
_____Total Section O

Only Females Answer Section P
_____P.01. Menstruates too frequently?
_____P.02. Acne worse at menses?
_____P.03. Scanty or missed menses?
_____P.04. Painful or tender breasts?
_____P.05. Have had hysterectomy?
_____P.06. Mood changes or irritability before menses?
_____P.07. Painful menses or cramping during menses?
_____P.08. Menstruation excessive or prolonged?
_____P.09. Menopausal depression?
_____P.10. Have hot flashes?
_____P.11. Depression before menses?
_____Total Section P

Only Males Answer Section Q
_____Q.01. History of prostate problems?
_____Q.02. Decreased size and force of urinary stream?
_____Q.03. Reduced sex drive?
_____Q.04. Dribbling after urination?
_____Q.05. Frequent night urination?
_____Q.06. Feeling of incomplete bowel evacuation?
_____Q.07. Difficulty stopping urinary flow?
_____Q.08. Leg nervousness at night?
_____Q.09. Pain on side of legs or on inside of heels?
_____Total Section Q

_____R.01. Chest pain or shortness of breath on exertion?
_____R.02. Swollen ankles, worse at night?
_____R.03. Personal or family history or cardiovascular disease?
_____R.04. High cholesterol or triglycerides?
_____R.05. Pain under sternum that radiates to the left shoulder?
_____R.06. Air hunger, sigh frequently or labored breathing?
_____R.07. Irregular heartbeat?
_____R.08. Snores while sleeping?
_____R.09. Pain, cramp or tired feeling in foot, calf and hip?
___Total Section R

_____S.01. Have bronchial asthma or bronchitis?
_____S.02. Frequent lung congestion?
_____S.03. Live or work around people who smoke?
_____S.04. Recurrent sinus or upper-respiratory infections?
_____S.05. Chronic cough?
_____Total Section S

_____T.01. Recurrent bladder or kidney infections?
_____T.02. Painful burning when passing urine?
_____T.03. Cloudy, rose-colored, or strong-smelling urine?
_____T.04. Difficulty urinating?
_____T.05. Urinary leakage or bedwetting?
_____T.06. Back pain in kidney area?
_____T.07. History of kidney problems?
_____T.08. Have skin eruptions such as psoriasis or eczema?
_____Total Section T

_____U.01. Pain in neck or shoulders?
_____U.02. Tightness in shoulder muscles?
_____U.03. Muscle cramps or spasms?
_____U.04. Muscles and joints sore all over?
_____Total Section U

_____V.01. Joint pain in hands or fingers?
_____V.02. Told you have arthritis?
_____V.03. Joint stiffness?
_____V.04. Told you have herniated or slipped disc?
_____Total Section V

_____W.01. Bones are sore or pain in fingers?
_____W.02. Cavities or dentures?
_____W.03. Gums bleed easily?
_____W.04. Have muscle cramps?
_____W.05. Told you have bone loss or Osteoporosis?
_____Total Section W

_____X.01. Uncoordinated or unsteady walk?
_____X.02. Pins and needle burning sensation in in hands or feet?
_____X.03. Muscle weakness or reflex loss?
_____X.04. Loss of sense of vibration in legs?
_____X.05. Memory loss?
_____X.06. Restless leg?
_____X.07. Dizziness?
_____X.08. Irritable or moody?
_____Total Section X

_____Y.01. Chronic infections?
_____Y.02. Wounds heal slowly?
_____Y.03. Loss of sense of taste and smell?
_____Y.04. Fatigued?
_____Y.05. White spots under fingernails?
_____Total Section Y

_____ZA.01. Night vision poor?
_____ZA.02. Strong light irritates eyes?
_____ZA.03. Noises in head or ringing in ears?
_____Total Section ZA

_____ZB.01. Vulnerable to insect bites?
_____ZB.02. Loss of muscle tone or heaviness in arms and legs?
_____ZB.03. Worrier, feel insecure, or highly emotional?
_____ZB.04. Slow pulse or irregular heartbeat?
_____ZB.05. Poor appetite?
_____Total Section ZB

_____ZC.01. Burning sensation in mouth?
_____ZC.02. Cannot recall dreams?
_____ZC.03. Numbness in hands and/or feet?
_____ZC.04. Intolerance to MSG?
_____Total Section ZC

_____ZD.01. Intolerance to sulfites (found in wine)?
_____ZD.02. Sensitive to perfumes or smells?
_____Total Section ZD

_____ZE.01. Frequently irritable?
_____ZE.02. Easily startled or nervous?
_____ZE.03. Muscle, leg, or toe cramping at rest?
_____ZE.04. Body odor or foot odor?
_____ZE.05. Crave chocolate?
_____Total Section ZE

_____ZF.01. "Lump" in throat?
_____ZF.02. Dry mouth, eyes or nose?
_____ZF.03. Gag easily?
_____Total Section ZF

_____ZG.01. Fatigued all the time?
_____ZG.02. Nails weak or ridged?
_____ZG.03. History of anemia?
_____ZG.04. Hands and feet often cold?
_____ZG.05. Crave ice?
_____ZG.06. "Whites of eyes are blue tinted?
_____Total Section ZG

_____ZH.01. Gums bleed easily?
_____ZH.02. Bruise easily?
_____Total Section ZH

_____ZI.01. Poor wound healing?
_____ZI.02. Dry skin?
_____ZI.03. Vision blurred or impaired?
_____ZI.04. Chronic infections?
_____ZI.05. Frequent skin problems?
_____Total Section ZI

The results of this health analysis can take up to a week for a reply.

Call or e-mail ron@belkraft.com

As a Natural Health Consultant, Ron will be happy to answer any questions on health and nutrition.

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