THE OPTIMUM WELLNESS CENTER



BODY CHEMISTRY HEALTH ASSESSMENT

All Evaluations include recommended protocol(s), eating alternatives and a Food Combining Chart. All for only $21!

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 PART ONE
 Check any of the following medications you are taking:
  Antacids   Chemotherapy   Hormones   Laxatives
  Antidepressants   Radiation   Lithium   Diuretics
  Cortisone   Thyroid   Relaxants/Sleeping Pill   Tylenol
  Aspirin   Antibiotic/Antifungal   Anti-Inflammatory   Ulcer Medications
  Vitamins & Minerals   Antidiabetic/Insulin   Heart Medications   Antibiotic/Antifungal
  High Blood Pressure   Oral Contraceptives   Recreational Drugs   Other

 PART TWO
List 5 of your major health concerns in order of their importance:


 PART THREE
INSTRUCTIONS: Select symptoms that apply and hit the SEND button at the bottom of this form. If you're not sure of a question leave it blank.

Questionaire Key
  • NEVER (does not apply)
  • MILD (occurs once or twice a year)
  • MODERATE (occurs several times a year)
  • SEVERE (you are aware of it almost constantly)

    CATEGORY I
    Section A:

    1. Bad breath, halitosis
      Never   Mild   Moderate   Severe

    2. Loss of taste for high protein foods
    (meat, etc.)
      Never   Mild   Moderate   Severe

    3. Burning ("acid") or nervous stomach,
    eating relieves
      Never   Mild   Moderate   Severe

    4. Gas shortly after eating
      Never   Mild   Moderate   Severe

    5. Indigestion 1/2 to 1 hour after eating, that
    lasts 3-4 hours
      Never   Mild   Moderate   Severe

    6. Difficulty digesting fruits or vegetables;
    undigested foods found in stools
      Never   Mild   Moderate   Severe

    7. Acid or spicy foods upset stomach
      Never   Mild   Moderate   Severe


    Section B:

    8. Lower bowel gas and or bloating several
    hours after eating
      Never   Mild   Moderate   Severe

    9. Feet burn
      Never   Mild   Moderate   Severe

    10. "Whites" of eyes (sclera) yellow
      Never   Mild   Moderate   Severe

    11. Dry skin, itchy feet and/or skin
    peels on feet
      Never   Mild   Moderate   Severe

    12. Brown spots or bronzing of skin
      Never   Mild   Moderate   Severe

    13. Bitter metallic taste in mouth
      Never   Mild   Moderate   Severe

    14. Blurred vision
      Never   Mild   Moderate   Severe

    15. Headache over eyes
      Never   Mild   Moderate   Severe

    16. Feel nauseous, queasy or gag easily
      Never   Mild   Moderate   Severe

    17. Color of stools light brown or yellow
      Never   Mild   Moderate   Severe

    18. Greasy or high fat foods cause distress
      Never   Mild   Moderate   Severe

    19. Pain between shoulder blades
      Never   Mild   Moderate   Severe

    20. Dark circles under eyes
      Never   Mild   Moderate   Severe

    21. "Acid" breath
      Never   Mild   Moderate   Severe

    22. History of gallbladder attacks, gallstones
    or gallbladder removed
      Never   Mild   Moderate   Severe

    23. Appetite reduced
      Never   Mild   Moderate   Severe


    Section C:

    24. Coated tongue or "fuzz "debris on tongue
      Never   Mild   Moderate   Severe

    25. Pass large amounts of foul smelling gas
      Never   Mild   Moderate   Severe

    26. Irritable bowel or mucous colitis
      Never   Mild   Moderate   Severe

    27. Constipation, diarrhea alternating or
    stools alternate from soft to watery
      Never   Mild   Moderate   Severe

    28. Bowel movements painful or difficult,
    constipation, and/or laxatives used
      Never   Mild   Moderate   Severe

    29. Burning or itching anus
      Never   Mild   Moderate   Severe


    CATEGORY II

    30. Head congestion/"sinus fullness"
      Never   Mild   Moderate   Severe

    31. Sneezing attacks
      Never   Mild   Moderate   Severe

    32. Dreaming, nightmare-like bad dreams
      Never   Mild   Moderate   Severe

    33. Milk products and/or wheat products
    cause distress
      Never   Mild   Moderate   Severe

    34. Eyes and nose watery
      Never   Mild   Moderate   Severe

    35. Eyes swollen and puffy
      Never   Mild   Moderate   Severe

    36. Pulse speeds after meals and/or heart
    pounds after retiring
      Never   Mild   Moderate   Severe


    CATEGORY III
    Section A:

    37. Crave sweets or coffee in afternoon or
    mid-morning
      Never   Mild   Moderate   Severe

    38. Hungry between meals or excessive
    appetite
      Never   Mild   Moderate   Severe

    39. Overeating sweets upsets
      Never   Mild   Moderate   Severe

    40. Eat when nervous
      Never   Mild   Moderate   Severe

    41. Irritable before meals
      Never   Mild   Moderate   Severe

    42. Get "shaky" or light-headed if meals
    delay
      Never   Mild   Moderate   Severe

    43. Fatigue, eating relieves
      Never   Mild   Moderate   Severe

    44. Heart palpitates if meals missed or
    delayed
      Never   Mild   Moderate   Severe

    45. Awaken a few hours after sleep,hard to
    get back to sleep
      Never   Mild   Moderate   Severe


    Section B:

    46. Muscle soreness after moderate exercise
      Never   Mild   Moderate   Severe

    47. Vulnerability to insect bites
    (especially fleas and mosquitoes)
      Never   Mild  M oderate   Severe

    48. Loss of muscle tone or "heaviness" in
    arms or legs
      Never   Mild   Moderate   Severe

    49. Enlarged heart and/or heart failure
      Never   Mild   Moderate   Severe

    50. Worrier, feel insecure and/or highly
    emotional
      Mild   Moderate   Severe

    51. Pulse slow/below 65 or irregular pulse
      Yes   No


    CATEGORY IV
    Section A:

    52. Sex drive increased
      Never   Mild   Moderate   Severe

    53. "Splitting" type headaches
      Never   Mild   Moderate   Severe

    54. Memory failing
      Never   Mild   Moderate   Severe

    55. Reduced tolerance for sugar
      Never   Mild   Moderate   Severe


    Section B.

    56. Sex drive reduced or absent
      Never   Mild   Moderate   Severe

    57. Abnormal thirst
      Never   Mild   Moderate   Severe

    58. Weight gain around hips or waist
      Never   Mild   Moderate   Severe

    59. Tendency to ulcers or colitis
      Never   Mild   Moderate   Severe

    60. Increased ability to eat sugar without
    symptoms
      Never   Mild   Moderate   Severe

    61. Menstural disorders (women)
      Never   Mild   Moderate   Severe

    62. Lack of mensturation (young girls)
      Never   Mild   Moderate   Severe


    Section C:

    63. Difficulty gaining weight, even if large
    appetite
      Never   Mild   Moderate   Severe

    64. Heart palpitations
      Never   Mild   Moderate   Severe

    65. Nervous, emotional, and/or can't work
    under pressure
      Never   Mild   Moderate   Severe

    66. Insomnia
      Never   Mild   Moderate   Severe

    67. Inward Trembling
      Never   Mild   Moderate   Severe

    68. Night Sweats
      Never   Mild   Moderate   Severe

    69. Fast pulse at rest
      Never   Mild   Moderate   Severe

    70. Intolerant to high temperatures
      Never   Mild   Moderate   Severe

    71. Easily flushed
      Never   Mild   Moderate   Severe


    Section D:

    72. Difficulty losing weight
      Never   Mild   Moderate   Severe

    73. Reduced initiative and/or mental
    sluggishness
      Never   Mild   Moderate   Severe

    74. Easily fatigued, sleepy during the day
      Never   Mild   Moderate   Severe

    75. Sensitive to cold, poor circulation
    (cold hands and feet)
      Never   Mild   Moderate   Severe

    76. Dry or scaly skin
      Never   Mild   Moderate   Severe

    77. "Ringing" in ears/noises in head
      Never   Mild   Moderate   Severe

    78. Hearing impaired
      Never   Mild   Moderate   Severe

    79. Constipation
      Never   Mild   Moderate   Severe

    80. Excessive falling hair and/or coarse hair
      Never   Mild   Moderate   Severe

    81. Headaches when awaken/wear off
    during day
      Never   Mild   Moderate   Severe
    Section E:

    82. Blood pressure increased
      Never   Mild   Moderate   Severe

    83. Headaches
      Never   Mild   Moderate   Severe

    84. Hot flashes
      Never   Mild   Moderate   Severe

    85. Hair growth on face or body
    (Question to females)
      Never   Mild   Moderate   Severe

    86. Masculine tendencies
    (Question to Females)
      Never   Mild   Moderate   Severe


    Section F:

    87. Blood pressure low
      Never   Mild   Moderate   Severe

    88. Crave salt
      Never   Mild   Moderate   Severe

    89. Chronic fatigue/get drowsy
      Never   Mild   Moderate   Severe

    90. Afternoon yawning
      Never   Mild   Moderate   Severe

    91. Weakness/dizziness
      Never   Mild   Moderate   Severe

    92. Weakness after colds/slow recovery
      Never   Mild   Moderate   Severe

    93. Circulation poor
      Never   Mild   Moderate   Severe

    94. Muscular and nervous exhaustion
      Never   Mild   Moderate   Severe

    95. Subject to colds, asthma, bronchitis
    (respiratory disorders)
      Never   Mild   Moderate   Severe

    96. Allergies and/or hives
      Never   Mild   Moderate   Severe

    97. Difficulty maintaining manipulative
    correction
      Never   Mild   Moderate   Severe

    98. Arthritic tendencies
      Never   Mild   Moderate   Severe

    99. Nails weak, ridged
      Never   Mild   Moderate   Severe

    100. Perspire easily
      Never   Mild   Moderate   Severe

    101. Slow starter in morning
      Never   Mild   Moderate   Severe

    102. Afternoon headaches
      Never   Mild   Moderate   Severe


    CATEGORY V
    Section A:

    103. Frequent skin rashes and/or hives
      Never   Mild   Moderate   Severe

    104. Muscle-leg-toe cramping at rest
    and/or while sleeping
      Never   Mild   Moderate   Severe

    105. Fever easily raised/fevers common
      Never   Mild   Moderate   Severe

    106. Crave Chocolate
      Never   Mild   Moderate   Severe

    107. Feet have bad odor
      Never   Mild   Moderate   Severe

    108. Hoarseness frequent
      Never   Mild   Moderate   Severe

    109. Difficulty swallowing
      Never   Mild   Moderate   Severe

    110. Joint stiffness after rising
      Never   Mild   Moderate   Severe

    111. Vomiting frequent
      Never   Mild   Moderate   Severe

    112. Tendency to anemia
      Never   Mild   Moderate   Severe

    113. 'Whites' of eyes (sclera) blue
      Never   Mild   Moderate   Severe

    114. "Lump" in throat
      Never   Mild   Moderate   Severe

    115. Dry mouth-eyes-nose
      Never   Mild   Moderate   Severe

    116. White spots on finger nails
      Never   Mild   Moderate   Severe

    117. Cuts heal slowly and/or scar easily
      Never   Mild   Moderate   Severe

    118. Reduced or 'lost" sense of taste and/or
    smell
      Never   Mild   Moderate   Severe

    119. Susceptible to colds, fevers, and/or
    infections
      Never   Mild   Moderate   Severe

    120. Strong light irritates eyes
      Never   Mild   Moderate   Severe

    121. Noises in head or ringing in ears
      Never   Mild   Moderate   Severe

    122. Burning sensations in mouth
      Never   Mild   Moderate   Severe

    123. Numbness in hands and feet
    (extremities "go to sleep")
      Never   Mild   Moderate   Severe

    124. Intolerant to monosodium glutamate
    (MSG)
      Yes   No

    125. Cannot recall dreams
      Never   Mild   Moderate   Severe

    126. Nose bleeds frequent
      Never   Mild   Moderate   Severe

    127. Bruise easily, 'black and blue" spots
      Never   Mild   Moderate   Severe

    128. Muscle cramps, worse with exercise
    ("charley horses')
      Never   Mild   Moderate   Severe


    CATEGORY VI

    129. Aware of heavy and/or irregular
    breathing
      Never   Mild   Moderate   Severe

    130. Discomfort in high altitudes
      Never   Mild   Moderate   Severe

    131. "Air hunger"/sigh frequently
      Never   Mild   Moderate   Severe

    132. Swollen ankles/worse at night
      Never   Mild   Moderate   Severe

    133. Shortness of breath with exertion
      Never   Mild   Moderate   Severe

    134. Dull pain in chest and/or pain radiating
    into left arm, worse on exertion
      Never   Mild   Moderate   Severe


    CATEGORY VII Female Only

    135. Premenstrual tension
      Never   Mild   Moderate   Severe

    136. Painful menses (cramping, etc,)
      Never   Mild   Moderate   Severe

    137. Menstruation excessive or prolonged
      Never   Mild   Moderate   Severe

    138. Painful/tender breasts
      Never   Mild   Moderate   Severe

    139. Menstruate too frequently
      Never   Mild   Moderate   Severe

    140. Ache, worse at menses
      Never   Mild   Moderate   Severe

    141. Depressed feelings before
    mensturation
      Never   Mild   Moderate   Severe

    142. Vaginal discharge
      Never   Mild   Moderate   Severe

    143. Menses scanty or missed
      Never   Mild   Moderate   Severe

    144. Hysterectomy/ovaries removed
      Yes   No


    145. Menopausal hot flashes
      Never   Mild   Moderate   Severe

    146. Depression
      Never   Mild   Moderate   Severe


    CATEGORY VIII Male Only


    147. Prostate trouble
      Never   Mild   Moderate   Severe

    148. Urination difficult or dribbling
      Never   Mild   Moderate   Severe

    149. Night urination frequent
      Never   Mild   Moderate   Severe

    150. Pain on inside of legs or heels
      Never   Mild   Moderate   Severe

    151. Feeling of incomplete bowel evacuation
      Never   Mild   Moderate   Severe

    152. Leg nervousness at night
      Never   Mild   Moderate   Severe

    153. Tire easily/avoid activity
      Never   Mild   Moderate   Severe

    154. Reduced sex drive
      Never   Mild   Moderate   Severe

    155. Depression
      Never   Mild   Moderate   Severe

    156. Migrating aches and pains
      Never   Mild   Moderate   Severe


     PART FOUR
    Symptoms that were not addressed above please include them below.



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