Full Name

Your ID Number

Your Weight in Kg

Your Hight in cm?

Phone Number

E-Mail Address

Questionare :

Which medications, if any, that you currently take have restrictions?

Symptoms of a Thin Myelin Sheathing:

Does noise, people or commotion get on your nerves?

Do you have to recheck things? (memory lost)

Do you have a hard time remembering your dreams every day (for about 20 min after awakening)?

Do you have a hard time concentrating when things are going on around you?

Do you have invasive thoughts?

Do you suffer to fall to sleep? even if you are tired

Do you forget where you are or what direction a place is that you have gone to often?

Do you always feel tired?

Do you forget common words or names?

Symptoms of a Weak or Toxic Liver:

How often do you have bowel movements?

Do you get night sweats?

Do the muscles in the shoulder/neck area get tight?

Do you feel bloated after you eat?

Do you have flatulence (passing gas) more than 1 time a week?

Do you have poor night vision?

Symptoms that the liver is not balancing blood sugar levels include: getting either shaky, weak, grouchy or aggressive. If you skip a meal do you experience any of the above? Or have you been diagnosed as having hypoglycemia?

Do you have diabetes or feel like taking a nap after you have eaten a large meal?

Do you wake up at night (to urinate or fluff the pillows or look at the clock, etc.) between 1 and 5 and then go back to sleep?

Do you have or have you ever had psoriasis, eczema, boils or acne?

Do you have or have you ever had moles or skin tags?

If female, do you have or have you ever had heavy or clotty, frequent or missed menses (periods or menstruation), or endometriosis? If male, mark never

If female, have you had fibroids, tumor in breast or uterus? If male, mark never

If female, do you have or have you ever had mood swings, PMS, or menopausal problems? If male, mark never

If female, do you have or have you ever had cysts on your ovaries? If male, mark never

Have you ever had hot flashes?

If male, have you ever had a high PSA or swollen prostate (including prostate cancer)? If female, mark never

What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol?

What is your total cholesterol number?

Are you on cholesterol medicine?

Have you ever had hepatitis or cirrhosis of the liver?

Symptoms of a pH imbalance -- acidosis or alkalosis :

Do you happen to know your saliva and urine pH? If so please put here

Do you suffer from sinusitis or have mucus in the head area or nasal drip?

Do food or pills feel like they get stuck in your esophagus?

Do you have any stiffness or cracking in your joints?

Do you experience muscle weakness or soreness?

Do you have more than 5 bowel movements a day or diarrhea?

Have you experienced a weakness or discomfort in the lower back?

Do you get acid reflux or heart burn?

Do you have high blood pressure?

Do you retain water or have puffiness under your eyes?

Does your heart ever beat ubnormal?

Do you crave chocolate or coffee?

Symptoms of a Glandular Weakness :

Do you feel as tired when you wake up as you did when you went to sleep?

Do you gain weight easily?

Do you experience sensitivity to the cold?

Do you experience mood swings and/or depression?

Have you noticed reduced initiative?

Do you have a lower level of stamina?

Do you now or have you ever had LOW blood pressure?

What is your date of birth?

Does your skin get dark where clothes or skin rubs (for instance around the pant waist band or bra or inner thigh)?

Do you have a hard time getting to bed early AND do you have a hard time awakening early in the morning?

Do you have an energy dip around 2 to 3 pm and then get your second wind later on?

Symptoms of Yeast Overgrowth :

Have you taken antibiotics or birth control?

Do you have dry or cracked or rough skin on your feet, heels or hands?

Do you feel the urge to urinate frequently OR when your bladder is not full?

Do you have chronic fatigue?

Do you get jock itch (male) or vaginal yeast infections (female)?

Do you get thick toenails or have fungus on your toenails?

Symptoms of a Weak Digestion :

Do you burp more than 2 times a week? (not including after drinking soda)

Do you have rough skin around your nails or hangnails on hands or feet?

Do you have a crease down the middle of your tongue?

Do you feel hungry soon after you eat?

Do you feel sick after you eat or if you skip a meal?

Symptoms of a Vitamin or Mineral Deficiency :

Do you crave milk products?

Do you crave sweets?

Do you crave salty foods?

Do you crave fatty foods?

Do you crave potato chips?

Do you crave alcohol?

Do you crave chocolate or coffee?

Do you crave ALL foods?

Do you have lower back pain?

Does your heart ever feel like it flutters, skips a beat or flip flops?

Do you get Charley horses (muscle cramps)?

Do you retain water?

Do you have high blood pressure?

Do you have hemangiomas (looks like a little blood mole), varicose veins, or spider veins?

Do your gums bleed when you brush your teeth?

Do you get cracks or sores in the corner of your mouth?

Do you have ridges in your fingernails?

Do your eyes get dry?

Have you every been diagnosed with a disease or health condition? If so please list all.

Are you on any medication which has diet or supplement restrictions?

Are you on a blood thinner?

Are you on SSRI's?

What is your birth date? MM/YR

What is your email?

How did you learn about The Window of Wellness?