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Health Questionnaire for the Health Challenged

Health Questionnaire & Suggestions, Questions for Health Challenged People

Health Questionnaire

Name: _________________________________

Address: _______________________________

City, State, Zip: __________________________

Phone-Cell: ______________________

Phone-Day: ______________________

Phone-Eve: ______________________

E-mail Address: ___________________

Questions & Suggestions

How much water do you drink?

What % is Raw vs. cooked?

How’s your complexion?

How often do you have an elimination?

Do your stools have an odor?

Do they sink?

Does your urine have an odor and is it clowdy?

How is your digestion?

What foods do you crave?

Do you have gas or bloating?

Get Eugain, (Lactoprive forte).

Go to my web page and pull down Products and Uses.

Recommended Wellness Program, Testimonials, and Dining in the Raw.

Order “Sick and Tired” (it’s a text) and the PH Miracle both by Robert Young.
Click here for more Recommended Reading Materials.

We suggest that you eliminate wheat, dairy, soy, corn, eggs, sugar, alcohol, caffeine (coffee, black tea), carbonation (soft drinks and sparkling mineral water).

Only do what is an 8 or better and also has your name on it.

On a scale of 1 to 10, how high is your stress level with 10 being high.

On a scale of 1 to 10 how healthy are you now?

How old are you?

How long have you been out of balance?

What are the symptoms that you are experiencing now?

(For women) Are your periods regular?

How well do you sleep and for how long?

Do you get sleepy after you eat?

Are you allergic to any foods that you know of?

How often do you get sick?

What surgeries have you had?

If you are taking medications, what are they? Please remember to consult your health care professional if you are on any time of medication.

What kind of exercise do you do?

What do you eat?

Do you snack and on what?

When do you eat?



Daily Inspiration

 

How to take

Body Balance

Holly Wheeler's
Cell Saturation and Wellness Program
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News and Events

01.01.05 - Recommended Wellness Program updated.
02.24.05 - Another news item here.