Below is the Questionnaire that will need to be completed. Please send me an e-mail at Support@RegenerateNaturallyNow.com and I will send you this form as well as the two others to be completed and emailed back to me...
Directions: Please (Mark the boxes) for all of the (Symptoms) that you have had within the last (Three to Six months).This nutritional evaluation along with your personal profile will assist in the developement of your (Personal Natural Health Program).
Section 1 ( Score Two or more ) :
( ) Inflamed or bleeding gums ,bruises easily or pink (red) spots just under the skin
( ) Cuts or wounds heals slowly
( ) Antibiotic ,cortisone or aspirin use
( ) Smoke / Tobacco use
( ) Eat less than 4 citrus fruits and / or cabbage per week
( ) See poorly in dim light at night
( ) Loss of sense of smell or appetite
( ) Work under florescent lighting
( ) Need dark glasses mostly
( ) Rough & dry skin or blemishes / acne
( ) Frequent (2 year) infections (urinary,ear,throat,sinus,etc),
allergies or cold / flu
( ) Eat green & yelow vegetables and /or liver less than 3 times
per week
Section 2 ( SCORE: Two or More )
( ) Osteomalacia (softening or thinning weak bones) arthritis /
Osteoporosis
( ) Little or no exposure to sunlight or not eat ocean regularly
( ) Prone to dental cavities or decay
( ) Sore or tender ribs or breast bone
( ) Drink less than 6 glasses milk / yogurt or eat less
Than 9 oz. of cheese
( ) Canker sores,ulcers,or fever blisters
( ) Menstrual cramps
( ) Hand tremors,nervous,irritable or insomnia
( ) Irregular or fast pulse ( heart )
( ) Twitching or cramping muscles ( foot ,leg,etc. )
( ) "Blackened Out ",fits,epilepsy,or seizures
Section 3 ( Score: Two or more )
( ) Fertility problems / miscarriage
( ) Hands and feet cold (even in warm weather) or go to sleep
easily, (numbness) or poor circulation
( ) Menstrual disorders / discomfort or hot flashes
( ) History of blood clot or phlebitis (inflamed vein) or
hardening of arteries (arteriosclerosis)
( ) Muscle wasting,swelling or stretch marks
( ) Swollen veins (varicose veins) or small blood vessels
show on cheek,nose,or ankles
( ) Chest and / or left arm pains or heart problems
( ) Arthritis / rheumatism
( ) Cysts or tumors
Section 4 ( Score: Two or More )
( ) Hair brittle,dry or lusterless or dandruff
( ) Nails break, peel or crack
( M ) Dry skin,eczema,acne,dermatititis or psoriasis
( ) Canker sores or fever blisters (herpes)
( ) Consume less than 2 tps of unsaturated cold pressed oil
per day (corn,safflower,nuts,soy and / or olive etc.)
( ) Stiff or achy joints
Section 5 ( Score: Two Or More )
( ) Poor eating habits - regulary eat prepackaged,canned,
processed or imitation foods
( ) Eat out often (more than 4 times per week)
( ) Fatigue / under pressure - stress
( ) Presently take a multivitamin
( ) Prenatal / breast feeding
( ) Personal injury or surgery
Section 6 ( Score: Two or More )
( ) Fatigue or tires easily
( ) Prickling or numb sensation or tenderness
( ) Twitching muscles
( ) Cracks or sores in corner of mouth
( ) Eyes sensitive to light,tires easily,blood shot,burning or
itching or feeling of sand in eyelids
( ) Oily skin and / or hair or dry scaly skin or dandruff
( ) Under pressure (stress) or tension
( ) Dark red tongue,sore mouth,or canker sores
( ) Indigestion,diarrhea,coated tongue,poor appetite or
nausea
( ) Depression,forgetfulness,confusion,or hard to
concentrate
( ) Arthritis
( ) Ringing in ears ,allergies,or asthma
( ) Dizziness,faint,"blackout",fits epilepsy,seizures
or chronic headaches
( ) Use oral Contraceptives
( ) Swollen (puffy) ankles,feet,hands,eyelids or below eyes
( ) Nervous / irritable
( ) Diabetes or hypoglycemia (low blood sugar)
( ) Eat white bread,prepackaged,canned,processed
or imitation foods regularly
Section 7 ( Score: Two or More )
( ) General weakness,fatigue, and poor reflexes
( ) Diarrhea
( ) Sweats often or live /work in hot climate
( ) Muscle cramps / spasms
( ) Low potassium levels
( ) Athletic / exercise often or very active
Section 8 ( Score: Two or More )
( ) Anemia
( ) Fatigue,tired or muscular weakness
( ) Sore tongue or mouth and poor appetite
( ) Hands or feet tingle,or "needles or pins "
( ) Eat green vegetables and / or liver less than 3 times
per week
( ) Longitudinal ridges,spoon-shaped or flat fingernails
( ) Fingernails pale instead of pink-red
( ) Hands pale or skin pale
( ) Shortness of breath or dizzy spells
Section 9 ( Score: Two or More )
( ) High blood pressure
( ) Circulation problems or aarteriosclerosis
( ) Constipation
( ) Hard to lose weight / obesity
( ) Liver,gallbladder or kidney problems
( ) High cholesterol or triglycerides
( ) Skin inflammation,eczema,or dry scaly skin or
hair loss
( ) Alcoholism
( ) Take birth control pills
Section 10 ( Score: Two or More )
( ) Poor circulation / arteriosclerosis
( ) Cold hands or feet -evening war weather
( ) High cholesterol or triglycerides
( ) Heart disease
( ) Varicose veins
( ) Depression,forgetfulness,confusion,or hard to
concentrate
( ) Recuring headaches
( ) High blood pressure ( hypertension )
( ) Difficulty breathing or out of breath
( ) Acne
( ) Pellagra (diarrhea,dementia & dermatitis
Section 11 ( Score: Two or More )
( ) Overweight and / or hard to lose weight
( ) Feet cold even in warm weather
( ) Puffy or swollen eyes,hands or feet
( ) Goiter (now or past ) or thyroid condition
( ) Loss of or diminished sex drive
Section 12 ( Score: Two or More )
( ) I do not consume protein (meat,fish,milk,beans,nuts or
etc.) at 2 or more meals per day
( ) Skip meals or eats " fast " food or food substitutes
( ) Low resistance,heals slowly or excess stress
( ) Poor muscle,skin or hair tone
( ) Need to lose weight
( ) Need liquid / soft diet
( ) Pre / post surgury
Section 13 ( Score: Two or More )
( ) Constipation / diarrhea
( ) Colitis,stomach cramps,or mucous in stool
( ) Acne or unpleasant body ordor
( ) Stool has foul smell,undigested food or gas
( ) Coated tongue or unpleasant mouth ordor
( ) High cholesterol or circulation problems
( ) Do not eat whole grain cereal / bread,bran,fruit / vegetables
and / or brown rice foods more than once per day
Section 14 ( Score: Two or More )
( ) Eats / fast
( ) Oral / rectal gas or bloating
( ) Indigestion / heartburn
( ) Bad breath,coated tongue or constipation
( ) Heavy,full,logy feeling after eating
( ) Gallbladder disorder
( ) Stool has undigested food,floats or foul ordor
Section 15 ( Score: Two or More )
( ) Insomnia
( ) Muscle spasms ,tremble or twitch
( )Awake after a few hours of sleep
( ) Backache
( ) Tight /pulled muscles
( ) Muscle crammps
( ) Nervous or irritable
( ) Stress / tension or worry
Section 16 ( Score: Two or More )
Females Ony Section
( ) Premenstrual tension ( PMS )
( ) Menses excessive or prolonged
( ) Menses Scanty or missed
( ) Discomforting periods (need to take aspirin,gain weight,acne,
cramps or breast tenderness )
( ) Infertility
( ) Take birth conthol pills
( ) Premenopause
( ) Loss or diminished sex drive
Section 17 ( Score: Two or More )
( ) Arthritis
( ) Stiff neck - whiplash
( ) Muscle or joint stiffness
( ) Swollen,burning or aching joints
( ) Tendonitis / bursitis
( ) Bachache
( ) Intervertebral disc problems
( ) Sprains
( ) Personal injury (accident / exercise )
( ) Bone Fracture
( ) Carpal Tunnel
( ) Damp weather increases joint pain
When you complete and submit your:
1) My Profile
2) Nutritional Questionnaire
3) Informed Consent Form and (Nutritional data plus Payment data) will get your Personal health program evaluated and submitted back to you with lifestyle and nutritional recommendations to assist you in improving your natural health !
