Dr. Wallach'S Self Evaluation Health Questionnaire Page 2
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2Dr. Wallach’s Self Evaluation Health Questionnaire
Rate Yourself: The Higher The Score In A Category, The More Likely You Have A Nutritional Deficiency In That Category.
0= Never
1= Rarely
2= Occasionally
3= Often
4=Almost Always
5= Always
Today’s Date ____________
Category 1 - Hard Tissue Problems
Category 2 - Soft Tissue Problems
Do you have...
Today
30 Days
90 Days
6 Months
Do you have...
Today
30 Days
90 Days
6 Months
Any Problems From Category 1 on Page 1
Any Problems From Category 2 on Page 1
Back Pain, Neck Pain
Are You Forgetful
Stiff Shoulders, Headaches
Trouble Breathing
Numbness, Foot/Arm Fall Asleep
Eye or Eyesite Problems
Trouble Falling Asleep
Age Spots, Blemishes
Bleeding Gums, Cavities
Gray Hair, Wrinkles,, Hemorrhoids
Kidney Stones, Bone Spurs
Do You Take Cholesterol Medication
Knee, Shoulder, Joint Pain
Do You Take Blood Thinners or Diuretics
Do You Take Pain Killer Medication
Do You Take Fibromyalgia or MS Medication
Do You Take Blood Pressure Medication
Do You Take Alzheimer or Parkinson Meds
Total
Total
Category 3 - Blood Sugar Problems
Category 4 - Digestion Problems
Do you have...
Today
30 Days
90 Days
6 Months
Do you have...
Today
30 Days
90 Days
6 Months
Any Problems From Category 3 on Page 1
Any Problems From Category 4 on Page 1
Get Sleepy After Meals
Stomach or Intestinal Pain
Cravings For Sugar or Sweets
Bloating or Gas
Sweat Exessively or Have Exessive Thirst
Any Type of Allergies
Wake Up Durning The Night
Constipation or Diarrhea
Trouble Losing Weight
Immume System Problems/Get Sick
Trouble Controling Your Blood Sugar Levels
Do You Take Anti-Acids or Stomach Meds
Do You Take Blood Sugar Medication
Fiber or Medication For Constipation
Do You Take Mood Swing Medication
Medication For Chrone Disease
Do You Take ADD, ADHD, Autism Medication
Immune System Medication
Total
Total
Do you have any other health problems that were not covered in the above questionnaire? ________________________________________________________
Is There Anything Else You Would Like To Improve About Your Health?
For More Information On How
More Energy
Lose Weight
Heart Disease Prevention
Cancer Prevention
Anti-Aging Prevention
To Improve Your Health And
Fix These Health Problems
Dr. Wallach’s Health Challenge To You... If you could change anything about your health, what would you change?
Call or email me
________________________________________________________________
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Parent category: Business