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)