Health Assessment Questionnaire

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After entering contact and 'primary health concerns' information, please select a number for each symptom.  If the symptom does not pertain to you select 0.  If the symptom is mild select 1, if moderate select 2, if severe select 3.
Contact Information

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What are your primary symptoms or concerns

Category 1: Hyperacidity

Category 2: Hypochlorhydria

Category 3: Small Intestine/Pancreas

Category 4: Colon

Category 5: Gall Bladder

Category 6: Hypoglycemia

Category 7: Insulin Resistance

Category 8: Adrenal Fatigue

Category 9: Adrenal Stress

Category 10: Underactive Thyroid

Category 11: Overactive Thyroid

Category 12a: Prostate

Category 12b: Andropause

Category 13a: Menstruation

Category 13b: Menopause (Menopausal Females Only)