NUTRI-BODY ® Questionnaire by Davia W, Rowland, PRD copyright © Rowland Formulas In. 2006 ‘is more important o know the pereon who bas the condition than its te Know the codon the person has" =-Hippocrass [NAME (Print) Sex Age Address _—_ _ Phone City Prov./Stae Post/Zip Code Date iFirst Test Cl Repest Test Date of Last Test. ‘his questionnaire is designed o assess bodily signs which may elate to nurtonal imbalance. is sole purpose & fo educate ord 10 form. isnot tended to eldgnose diseases. if you suspect that you ‘may have a medical problem, please seek competent medical coe. TO COMPLETE THs FORM: any pat ofa statement fue for you, PLAGE @ "1", "2" OR “Sn the BRACKETS beside it Use “I” for * sometimes” or ‘mild "2 for”often” or “moderate” and “3” for “very often” or “severe” Ski all statements ht de net oppo you. he end ofeach ecto ot he mbes ebro ond ‘multiply byte foctorindcated. Do not “agonize” over any statement. itis unclear or questonoble, Ignore and go on tothe next. 1 Dry mouth, dry eyes dry nasl membranes, ] Diy or leathery en, L Rough, dry, ako sealy skin [ Dry or chapped lp [ c t ) Bama, polis dermatitis. | Deyor rity feaing ney, dry tear ducts 1 Stool hard and dry. i } Love volume of rin, inate insequenty, } 1 Tendency to form Kidney stones. C C c J Doyles, or brite hi, split ends 3 Brite or eracked nals Dry mouth, throat, mucous membranes. L_] Wounds or injures heal hwy, pod _ Blading gums, easy brusing. L_] Frequent elds, infections, sickness [L_} Depresion, lack of motivation. [L_] Forgtulness, short attention pan C c er: Section A:2 } FINALE Premenstrual gudome FEMALE Diy geting gat or tying to [J Infrequent bowel movements. term, me { ] Pain, bovel moves. { ] Abdominal steno [J tom otapette —rmxs + () As {1 Haeorois ore fe {Orewa {1 Vaowe tes “RGIS RESERVE. eter amet or oy a {1 Tendene to orm alton ft nbd oboe in myfrmer ey os (clang phoecpig) or by an Infomedia ‘enn oat, te ents wuss () aa |seneeSection A-4 ) Excess fad retention edema) in had or fet. 4 Nausea or dizziness. ) Poor co-ardinaton. 4 Geneca, verl weakness, 3 Anemia, ) cataract, } Catch col, fy, nfeton easly } Cutlets 1 Muscle wasting, tissue os. 3 Impaired wound healing ) Premature eng ) Hair dll dry, spars, loos ad ling ot. 1 Brite nails, slow growing nals. 1 Mood swings, depression, 1 Iosomnia, 1 Nervousness, agitation ) Low resistance to stress —tomx s+ () aM Section A-5 1 old sows, erp simples. 1 High trigyerides in Blood. ) Inabligto concentrate 4 tet. 4 Bloodshot eyes. } Musee wasting. 1 Bxcessve helo, 2 Anemia en Section A-6 2} Museuar weakness, 3 Bite a 1 Allerg cherie senses, 1 Atherostleress cardiovascular dlsease. ) FEMALE: Fremenstrul syndrome. | FEMALE: Toxemia of presancy. rmx = (as Section A-7_ [1 Ansty. {| Headaches, migraine headaches. {(} Shortateation pen, hypetesion. [ } Poormemor. TE] Bwcessve appetite. [1 Depression, moodines. [1 Addicéve behaviours 1 Vitgs, ts of skin pigmentation, Om — rom x 6 Section A-8 } soma, sleeplessness. 1 Depresion, moodiness. 3 nsiey, pane atacks 1 Migzaine headaches. ) Ress les 3 Hypercti. 1 Lupus erythematous. rm x () As ‘Section BL | Indigestion or sourese 2 to br after eels, 4 Abdominal loting distension. 4 ull logy fain fe heawy meat mesh } Las of former taste or eravng for meat. 3 xcessve gas, belching or burping afer meals, 3 Baring sensation in stomach, heartburn 3 Heavy tied faling after eating. } Conetipation. } steals poorly formed, pale, greasy, Moatng. 3 Uadigestel fod particles in sols. | Ridgeson fingernail, slow growing nails. rm x6 = (7) BA ‘Section B-2 L_1 Stomaeh sin gor he. after esting usually night, relieved by eating orb drinking mil 1 Abovecomphints aggravated by wory/teasion, O —— TOTAL x 25Section B-3 1 Low tolerance to slcahl or sugar 1 Skin oly on nose and forehead. 1 Dark lrles or bags under the ees 1 Fets/greasy foods cause nse, headaches, 1 Stool eppears yellow, ely-coloured, foul odoured. 1 le greasy stools that oat. 1 Foul-smeling bowel gas 1 Bad bronth/bad taste in mouth, excess body odour. 1 Pain on inside of ight shoalder blade, 4 Consistent gas boating rom most foods, and ‘ede rom onions, cabbage, raises, ccambes. rm xs» (Bs Section Bea [J Greasy, futsmetng sols. [1 chronic diarhes. [1 Undigeste fod in ston, [ Mucusin stools [] Foul-smaling intestinal gus —— TOTAL x 10 = oO Bd Section BS 1 Indigestion, bloating after meas. ) Intestinal gas, especially ster sugary foods. 2} Diaieheao constipation. 3 Urinary tat infections 1 Yeast infections, candidiasis 2 Oo sores, canker sre waxes - (_) Bs Section C=. 1 Dental caviar, 1 Overweight. 1 Nervousness, hyperactivity. 1 Ansty or deprasion. 1 ravings, adios. 3 Yeast infections, eas 3 Recuring infections 3 igh cholesterol in blood 1 High triglycerides 1 Gallstones, gout oF Kidney stones, Oa ToL x 5 = Section C:2 [1 Highblood pressure. [J Stole dy, shrank, [_] Becess uid retention, edema [J Stomach ules { l | Tremors, evasion or seizures. 1 Highblood pressure 1 Iria, restlessoess excitement, 4 Nausea, vomiting 4 Headaches ) Convalsions, remors, ) Iaserais ) Frequent erinaton, bladder iitation, 1 regular heartbeat. 3 Ringing sound in en, nits 1] FEMALE: Fibrocytie bess ump, ww x6 = (CS) ca ‘Section C-4 1 High blod pressure [Shingles hives [Anemia —— TOTAL x 6 = C) « Section C:5 1 Whitish, yellowish orbrowe mating of teeth, 1 iting of eth, 1 Nansea or vomiting, | Pain and aching ofbones and spine TOTAL x 2 = CC cs £ t t CSection C6 (] Beciterent. {J Confusion (1 Depression [ ] Muscular withing. [Abdominal ramps. { ] Spusmodic muscle contractions. [ } Heart palpitations C1 Rapid breathing. —rmxs- (_) o6 ‘Section D-1 1 Brite ngeraie, verily edged na [Pain in forearm or beeps, [LJ Cuampe in eal muscle during sleep or exerci, [J Palnfl cramping of fet or tes [J Join pains Teeth prone to decay, fequenttothaches. 1 Poor quality o malformation ofbones [LJ Nervous es or twitches, witehing muses, [1 Nervousness, itailiy, ait [_] Uneval sensitivity to noise [1 tnsomnis. [] Hearepabpitations. [L_] FEMALE: Eacessiv, lengthy, painfl menses. rmx = () Da Section D-2. [1 Inttable nerves or muses, ervoustis/titches. [1 Masel spasms, tremors, conalsions or seizures, [3] Musele cramps in ott of feet [ ] Muscular tension, tight mass, Restless legen constant motion at night. [1 Kree pain hip pain. [3 Irregular heartbeat [3 Painful and cold hands or et, [7 Breasive body odose (3 Looseor sensitive tet 2 Anos confusion, dseiontation, iti [1 Nausea, czaines or iphtbeadednese Menta depeesion or apathy. L_ Strtle reactions, persensitvtytonolse. [ } Pooreo-ardination Cravings for ebootte. 1 Insomnia, restessnes, hyperactivity. ‘D2 continued 1 Repeated tapping of hands or feet. [Bone spurs. [Big Blood pressure rmx =) v2 ‘Section D-3 1 Sweling of anes or hands, J Dry skin. ) Slow, rapid or regular heartbeat, paptatons ) Constipation 4 Unusual tit. ) Moser wesknes } Unusually sore ors mules ster exereising, Soames O» 1 Highblood pressure Tom. x 6 ‘Section D-4 1 Pale skin, palms of ands very pale 1 Fingers very ight in colour [[_] Bngernalls at or eoneave (spoon shaped), J Tin, eagle, rite nals; vertical des on nals [1 Innerside wer eelid ie pale [ ] Lackofenduranes or stamina, emia, Leaving foie seating rmx = (a Section D:5 [] Proneto athletic jis strsned kes elbow. {Loss oftigament tone or strength [1 Muscular weakness, [Nervous degenerton [Creaking or clicking of ins, [1 Knee, hip or ankle pin, C) »s —— Tom x 8‘Section D-6 [1 Oxts, wounds, sores heal lowly. [ ] Hair ori grow slowly. [Laat ofsense of sme or taste [ ] Catehoolds i, infetions easy. [ ) Briton. [J White spots on fingernails. {J Acne [Stretch mers Steir impotence, _} White coating on tonne 1 kas of appetite, anorexi [ Seepeistrances, [1 Diarthes [1 MALE: Prostate problems lo sperm count [1 MALE: Delayed sero matty, [1 CHILDREN: Growing pains, stunted growth C) pes — Tora. x 4 Section D-7 [1 Dyein. (1 Daya [Brite o fag ai [1 Siow wound healing. [J dolnt pain, tenderness or sling {{] Muscular soreness, cramps in legs orback [J Diabetes, aiabetetendences, (1 Ansley or depression. rom. x =) va Section D-8 Rapid aging skin, os of skin asic, [Weakest thinning hte, split ends, T ] Softorweakaals. [Reade prov, incomplete set devdopment wm x= = (C) vs ‘Section E=1, [ ) Dept [3 Brienal [Stow mental enctions. [1 High hoesterol in boo {( ] Bnlargement of thyroid lan, gots [_] Heart palitations E) Ieeabiiy (1 Overveight [J Stuggsh metabotsm. t c [High cholesterol in bood (1 High trgerides { Lintlerance to alesbot, [] Glucose intolerance, typrlycomia, diabetes. [Cravings or sugstsorstarches. rom x0 = (CO) ee ‘Section E-3 1 nussalardegenoraton, moseuar dytropy. Weakened hosr tame, ardomvopsthy. 1 Los of skin elastic, excessive wrinkling 3 Canoer orhear disease 1 Catarats, 1 Optic fibrosis. tom x0 - (_) BS Section E-1 LL} Poor ight sion, unabeto soe welin dim ight [1 Byes sense to glare, sunlight or bight igs {LI to adjust eyes wher entering a dark room. [1 Dryeyes, dry comes. [1 Byte red scaly or dy { ] Byelnfammations, conjunctivitis {1 siyes, eid svoten, [J Gets orespirsory infections easily.E-L continued {Sina probloms. 1 bsceses in est, mouth or slivary lads. [1 Bite o ry hae, {1 Diy rough or seal skin {[] Hard "oosebumps on back of ams. [1 Acne, pimples orbaeHhends. (1 Wars. C1 ine, orinary or bladder infctins, burning or itching when urinating rmx (1) Ft Section 2 2 Burning n mouth an trot } Poor bone development 1 Abwovnal numer of ental cavities, cracking eth, ) Osteoporosis (demineralized bone) } Osteomalaciasftening of bone). 1 Rlckets bowlegs, noel knees). 1 Joint pains, bone pains. ) Muscaar cramps 1 Nearsightodness, myopia, 1 Nervousness. 1 Insomnia, 1 Constipation, —wmxs-+() Fe Section F-3 1 Moscalas woskess ewling or wasting [Poor coordination [1 Involuntary movements ofthe ees, [1 Bt and falling (1 Tendency to form blood dts. t C C C 4 Fatmalabsorption, aie sprue, esti ross, 3 Hemolticanemia, eke cell anemia 3 FEMALE: Meastrual discomfort |) MALE: Low se drive, impotence, ean — Tom. x 0 = ‘Section G-1. 1 Hear palpitations or allop rhythm, 4 Slow hear bet ] Diastolic Blood presse over 90. ) Foretfuiness, poor memory, shor atention span. 1 Muscular tndernes, weakness or wasting. 1 stably. 1 Feel depressed 1 Loss of appetite or los of weight | Numbaess, pricking or tnging in hands fet. } Loss of ankle or kee jo reflees, 1 Poor co-ordination, 1 Sites or swelling in ankles, fet or gs 1 ramping puns in legs, especialy ater errclang. 4 Tenderness in calf meee under pressure 3 Constipation 1 Valoeraity to insects, ep. mosquitos orflens —rmxs + (C) oe Section G2 [LJ cracks or ores in comer of mouth. [L_] Reddish-purple (magenta) coloured tongue [J Shia, sore orswelen tongve. [Lips re, whit, say swolen or chapped. TJ Conjunctivitis (1 cataraes. {Sensation of"sand” under the eyelids. [1 Byes sensitive to ight {1 Bred vision, dimming of vision, (1 Byes re thy, boring. [ ] Redline in whites ofeyes i i i C i tC } yale } Loss of fulness upper ip, 1 Wrinkles radiating fom lis towards nse/checks.NAME 0 DATE a [ater ma rive BS se at Aas Ms Prt aS tine Ms Moi a Phenboine aS [Typo Br [Lor Seach Ald 3a igh Somach Aca Ba [vera miner Ba Matatorton 3 Last baceri ei Super cos @ Somes Cy cafe ca [cnorne ce wri a Newtee os [cao Da Magnes D3 [rows Da lon DE [Manganese Dé fame Ds sehr Ds sakon Ei = 2 [Chenu Bs seein a [vienna @ Vania my Vitamina Viena or Vienne os ‘Nica a Poa Ad os Viana os ‘Bite ar Vionin os Fale oo Wisin mt Cote m2 Bistros uw co a Coa 2 Copper Bees nm Tad 1s Merry u ‘cera Aen 2 vrai Areal B ‘God u iden iE Pane as Vader Tyrid Hu vrcine Tyla o Piiary w Taya i ‘Arse 2 Nervous stom Ka (Cevtaton Ka ypenyemia Ks Intestin Parts Ké POMS. Ko CoanSection G-3 ) Diaries, 1 Ghapping of backs of hands 1 ey, ed orinfamed skin, dermatitis, | esa, emvety or depression. 1 Las of sense of humour. 2 Indigestion. 1 mall ers or canker sores ia mouth, 1 Burning sensation in hand or fet. 3 Insomals, 1 Wiis costed tongue. 4 Bilin ved pant tongue. 1 Swollen tongue wit ed tip and sides. } ela hands or fet go numb, wars (2) «es Section G-4 } Pops in eyes are unusually large, ate 1 Perid of deep depression } Baraing sensation of hands of } Poor co-ordination. 1 Lightheaded or dizzy when siting up or standing up. } Diarchea oF eonstigation Numbness o tingling in ands or feet. 1 Joint pais. 1 Musee eempe. J Rapid heartbeat on exertion 1 Itai, agitation, 1 Headaches. | Insomnia, sleplessnes. 1 Quarmlsme, bot emp. | Ina eope with sre. 1 Rests legs, constant motion oflegs at niht C) « tora. x 3 Section G-5 1 eraity or nervousness. 3 Real confaea 1 Canttremember dreams. 3 Diziness, 1 Swelling of hands, fet o anes (dems). } Unabeto close hands into ht, lt et, } Soreness, tenderness, weakness of hum muses, ] Greasy salines on skin near nose, mouth, eyes. 3) Muscular tithing. G-Scontinued 1 Greenish tint to urine 1 Hyperactivity. 3 Poor co-ardization i walking |] FEMALE: Nases of pregnancy. |) FEMALE: Aene worse doting pesods, |] FEMALE: Swellag of face, abdomen o extremities ving menses ures) os Section G-6 1 Shin shiny, dy and scaly. 1 Tongue purplishred (agent) swollen & pant 1 Navsea ) Muscular pine. | Mental depression, ) Poor appetite. ) Fingernail ple colour, pale compleson. ) Sleeplesnes 1 Irregular heat beat 1 Hairloss, brit ai 1 Los of kin pgment. rm xs CO) os Section G7 1 Sore, bey re tongue, J Lemon-ylowish int to skin, pa complexion. 1 Nabe tingling soreness, welnessinhands/et. 4 Secking offimbs. 1 Memory los. 1 stammer. 1 Apsty, fees fhe ost incentive ie, } Depresion, moodiness. 1 Anxiety, irabiiy, nervousness, gation. 1 Anemia, } Hatlucoaton,delurons 1 Los of appetite 1 Confusion, disorientation, 1 Bac pins. 3 ianes. 1 Dimmed vision. 1 Poor somach digestion, low stomach aid |] FEMALE: Menstrual disturbances, t C i C i i C C c C [ C c C C C c C mx (orSection G-8 Tongue red, shiny, smooth and pant [Ueto mouth, [Led swollen or bleeding gums. [Intestinal malabsorption, sproc. [Dares J Hear palpitations [Swelling of anes. ( Lghtheodedness, faintness. {Apathy or depression, (J Forgettness [J Lass ofappetie, weight los. £3 Greyng hai. {Brees pigmentation of sn, {liable agate, brooding or selteonsclous, (J Anemia wars - 6s Section G-9 {J Skinbriss easy, “lack blue marks, J Memorshages or ptared blood veses in eye. {1 Gums bleed easily, especialy when brushing eth {L ] Blish-zed, swollen or inflamed guns Loose tet, ls f dental lings. [L_] Cats sores or wounds hel slow L_] "Fleeting pins in joints or legs, joint tenderness. L_ cateh infections, colds, for viruses easly. [J Listeseness, lac of endurance, tie easly, T } Cutiles ea esi [ ] Bxeessve hairloss [_] Restessness ois. [Nosebleeds {Broken capiaries, hemorrhages pink spots on skin, {{] Bloting or putes in ee. [Anemia [1 Fragile bones [J Tinaing or prometur aging of sia. wm xs = (2) os Section H-1 [oem [1 High ood pressure [High choesterl evs [J Ler orkidaey disorder L } Poormemory. ee es Section H-2 [Bleed easily (gums, nosebleeds, cts). [1 Bruise easy [L_ ]Tinyred bec spots om an, [LJ Varicose velns, erorelds J tetamed,swolen ots. FEMALE: miscarriages, thestened miscarriages. [L_ | FEMALE: hony eprlonged mensiril bleeding rm xe = () wa Section Let [1 Rowgh skin. { Breasive perspiration, Lass of formar taste or ersving for mest [1 Nausea inctnation vomit {Potatoes disagree {L Belehing acompanied by head eos [Constipation secompaniedby throbbingheadaches [1 Nambnesstiffessorlesofsenstion inarms/lgs. { Poorar fing memory. {L_} Sttebng or burning pain in head with dines, relieved by eating —wmaxs = ()u 1 Nausea or vomiting, 4 Abdominal pin 3 iarthes 3 Bacesiehairtos 1 Piyperaciviy ably or erouness 1 Dopresson wuts (OsSection 1-4 Constipation. c Grams orvaguesbiomina aches or discomfort. [ ) Ditiness, t {3 Anxiety or ieritaity C [1 Nervousnes or restlessness C [ ] Lackofambiton, apathy or depression, c [ ] Hand temors. L [Poor ex ordination, C _] Saloweompletion, greyish greenish yew tint, [ { } Convulsions, setres c {1 Paralysis. [1] Catch cols, fntesons easily C1 Vomiting [1 CHILDREN: Hypersetvity rmx 4 = Co) [ . [ ‘Section 1-5 [ t 1 Tremors oc poor co-ordination, C 1 Inflamed gums c 1 Loss of abi to speak. c t c c {High bod preseare. (1 Diabetic tendencies, {_} Mental asturbanesor personality change. [1 Poormenory. {Doren ranting c c i i t 3:1 continued | Avid omplaints, ty to jgnore inconveniences, 1 Work of worries, thngsleft undone cause concern. J Alleles (eq, kin rsh, hay fever, astm, ee) 1 Mood swings tendeney o cry easily. 1 Ditty resxing 4 Emotional upets couse compete exhaustion. 3 Unusual erating fre. 1 erspire excessively, sweating of hand os fe. 1 More thun usual neck, head, shoulder tenon. 1 Blod pressure decreases when gong rom ying postion ta standing position, mms CO) a 1 Fersstnt high blod pressure 1 Rapid pale. 1 Fluid retention offal tases, pl fae. 4 Stronger shan average physically. 3 tong felngs, low up easily sik being erase | FEMALE: Eucese hai on foe, arm, leg. | MALE: Baldness, hairy erms and bie, muscular “square” build, agaressivein busines or sport, rmx s - () a2 te ‘Section J-3 FEMALE] 1 Allerg tendencies - 1 a fete {1 tel or dicmfertng mens periods. 1 Feed emvngs {| Hotta, ites 1 Pai an bakin, {U1 Nerounets depen, mood wings. 1 hast spree {1 Hveted snd ovr emo. 1 ii 1 Lamond sex de { } res evaig ere ding pints _ . , ‘nae ave chilren ene of erty (rt a amas Sencctansen Section LL —wmxe- (7) as {1 Byessesitheto right hs heads snp Section Je3 (MALE {Tpke orp” oho rr de sess. J Inability to cope with stressful events, C_] Difficulty urinating —starting, burning, [1 Form gooseflsh easily or “cold sweats. 1 Above associated with back or leg pains. {1 Voces tobighithoriest dngsteae, £2 Helo winnte meet vc dig night {1 Sasiystaken uporsartedfomunerpecednoise. [ } Prostate trouble or prostate sarge. {1 Preferbeingalone, uneasy whencentreofatention, [7 Lestor diminished sex drive, {Blood presente seins oo 1 Reel ants —wure. (JasSection J-4 {Burning sensation upon urination. [1 High iastli blood pressure (above 90). { ] Lower back pins. J Puttnes round ees [._] Haveto urinate more than twice per night. [3 Lagsotten fol bevy [Unable contl fw of wine, incontinence, [3 doin pains {1 Anemia rmx 6. (Co) Section 1-5 } Pinon ioside ofl shoulder bade 1 Puinon eft side of abdomen J Shingles on trunkof body. } Gaidhands or feet, ) Feloold and sweaty. 1 Shakiness, J Slow healing of wounds, ut, bresons. 3 Constant, intense hist 3 Usinatemore shan 2 izes daly. 4 Breath smeis west o of acetone 3 Tingling, burning, obs or numbness in hand fet 3 Vision alin. 1 Urine contains sugar 1 Moody with marked up nd downs 3 Cold sweats ofthe hands even when warm. 1 aintng, blaeing ou or convulsions. L c c c C C c C i [ t t t t C [ i } Vague, aaelated complains relieved by eating but retum wih a vengeance. ToL x 3 = @ as Section 1-6 1 busses iff in morning fel need tober up. 1 Failto fel rested, oven after sleeping lng hour. 1 Feal creaky” ater siting stl for ome time ) Heat eens to mis eat or tun pops ) Nautested in morming ) Startslow in morning } Motion sseness when trvelling | Ditzyin morning or when moving up and down. 3 Gold hands or fet. 1 Sensitivity tocol prefer warm climate, 4 Malrscanty, dy, rite dal Tasteless, ees. 4-6continued [Hairloss fom outer third of eyebrows. [1 Bak, dy, rough kin, [Lj Seplessness,restessnss, seep disturbances. [L_ Boorshore erm memory, frgetulnes [3 Poocresponse to exercising L_ 1 Rypelycemia ove blood supa {LJ Highebotsterol, cholesterol depots on eli [|] Constipation, les thas one bowel movement dally 1 "Goto pices easly, ery easily. (Lisle working under pressure, being watched. [L_ Diminished sx dev, lack of sexual dese LJ Gain weight easy, ull to os on des Lieut concentatng, easy distracted C i t t t i [ l t t t i t 4 Yellowish tnt to sin on hands or fee. 1 Cracks in bottom of els 1 Goggea sinuses. 1 Low pulse mite. 1 Lov bd temperature, specially at bed rest. 4 Recurrent infections 1 Depression | Headaches. ] Paffines of fae or ees, ] Swelling ofhands or anies, | Irby, mood eings, 1 Multiple fod alegies/sensivies. 1 These wore at night: eoughing, hosesenes, muscle cramps. (1 FEMALE: Lumpy breasts, tie brests. [ ] FEMALE: Menstrual regulary, exces ow, ee murs) Section.J-7 Terese |e C c [J Protrudingtongue quivers, hands shake or tremble [J Strong drive followed by exhaustion. LJ Good appetite but filo gain weight. [ati ighty” behviour, tarp [J Protrading eyeballs [1 Waem, fine, moist hin. [_ Ietbity, nervousness, hyperactivity, insomnia. [L_ ] Frequent bowel movements, dirzhes, _ Exeesive sweating without exercise [L_] Reelwarm flashed at normal oom temperature Ou — tom x 4‘Section J-8 ola hands or fet, cold lover 1 Infra o impotence _] Headache afeng one side ofhesd J Bxeesive urination [Left upper neck pein Left fnger pain [Overweight from wast down or from wast up. J Feelings ofinadequcy {LJ Changeabl temperament, moody. J Feelings dominate over logs [J Abdominal "apron of fat {Mid oveling in ankles, ingers, fe. J Pufines under eyes. [| FEMALE: Lost of mens fanction, er: Section 1-9. 1 Ghroni , vl infections. 3 Hay fv, alerses, allege hint 1 sth, eczema 1 wells glands in armpit, groin tonsil. 4 Festing of panes in thos Y 4 Soreness on both sides of neck at shoulder eel. 3 devgular heartbeat ) More than ural number ofeaiis, } Look older thn chranlogel ag. OC) » — Toa x 6 Section K-1 {Ave in morning not fon este. [L_] Analmost pain fatigue nt eld by et, {_] Davkor psy cries under the yes 1 Spastic colon, colts, etable bowel, [blir chron complains that ecu. [High ood pressore. [_] Bodwetng, eneontrliedurnstion, [J Balargement rym lands in neal, [Have ben called "hypochondie { Insomnia, hep disturbances [_] Memy sweating not elated o exercise. [i ezaion, [Muse spasms, sehing mses {Pat sor swollen joins. {Depression or eryng spells. K-Lcontinued {1 Sinus attacks. [ate eases [History of bronchitis or peumonis, £1 Byperaciviy. {Constipation o aires {[ } Marked tctuations in weight, 1 Bezema,peoriss, rashes, dermatitis [1 Ietaiiy. [ ] Mudderinfecions, [J Hay over, necaing attacks, Dry stuf nose, tendency o pick nose (Ram nose [J Boating or pufinesin fee, J Bronchial atta, [J] Migraine headaches, rmx: = x Section K-2 [Tremors ofhands or fet. LJ Double vision. J Sturoa speech. I Itabiiy or npatence, [Lose stamins wile doing physica work. [LJ Lose temper easily, emotionally unsetid. rm xs - () Ke Section K-3 {1 Ringers and/or toes go eld (1 Arms and/or legs "goo see. ] Numbness or heviness in ams or legs {[ } Grampsin hand when wring. {1 Sharp, dagonal reasein earobe. {1 Tingling sensation in ips or fingers {Short walk causes cramping opis la es [ ] Momory note good ated tobe, [3 Ankles sel ate dy l i t C i t C 1 Persistent, nagging cough 1 Breathlessness on slight exertion or lying down. 3 Urine more than wie daring night. 4 gh blood presse 1 Wish ring under outer part of cornea inthe oye 3 mpotent or fg } Guestpain atte physical exertion oremtionl tress lerSection K-4 ) Trelubleflte ora meal or miss me J Headaches that re woree after missing «mel 2} lelable before breakfast. 1 Baal peat frustrated, 1 Gonstant worrying | Riso anger, agitation, tamper outbursts, | Bbisodes of shakinesor tremors. | Sudden, strong cravings for sweets cole, aleohol | psodes of uncontrolable eating, binging | Asthmatic aac. 1 Ansley tacks, eying spell 1 Get hungry soon after eating 1 Sudden drop in energy n mid-morning or mia. | Fatigue or sleepiness fe eating, worse feat desert. } aldhandsor fet. | Wake op a night fling hungry | Wakeup in mile ofnight and eat go bac o tap. 1 Nervousness, shaky folings, depression or headaches relieved by eating sweets [_] CHILDREN: Attention dei or hyperactivity. rmx -(C_) k4 Section K:5 1 iarches or sbdominsl sree while sting foreign ‘or unfamililoaions 1 Unoepained indigestion, gs orbloating. {C]tntestina tae able, burns or eramps fr 0 apparent reason. 1] Recently developed fend/environmental alerges, [1 Frequent cols, so othe cute nes Ditty overcoming intestinal yeast overgrowth _] Ravenoos sppeste [Anal itehing oten worse at night L_ eelings of etal fulness or pressure C t C t 4 Weightloss or inability to gin weight } Muscular wasting or weakness. ) Lethargy, slow reflexes | Bowe movements changeable somtimes har, somattes sf, foro apparent reason. rmx «= () Ks ‘Section K-6 [FEMALE] Indiate which conditions apply only they oecur within 14 day pros to and todays fter the menstrual perio: [Anxiety nervous tesica, pounding hear (1 ental, restlessness { ] Depresson, nocd swings [J motion oaths crying pel (1 Headaches, dziness, fining (Backache cramp. ( } insomnia, [1 Bloating, weight ain [1 Fompestlzess, confusion. [increased appetite, raving for swoes [] Breastendemes, C1 Sweling of hands, fot, edema, C) xs Tor, x 4 ‘Section K-7. Repeated use of antibiotis orbits control pl. Laing or sugars, bread or aco [L_] Indigeston/ascomtore ater esting sor sweets, [L_} Severe reactions to perfume tobaco, chemical, [1 Totlerance to alcool [J Hypersenstity to certain foods T ] Diasbes oe constipation, {Rectal itcbingor badder nfstions. [1 Gostedor sore tongue (1 Chronic sore ar scat throat, orl thrush {Feel Badal over, withow spparent cause, {( Fealing being ina ment fog, spaciness” 1 Hives, psoriasis or kincash, [1 Ansty or depression. (4 Tiredness, etings of being "dslned [1 Athletes oot, toenal or Sager fungus, [1 Alergy or sensitivity to sirborne moulds (1 Allergy or sensitivity to monly or famented foods, [ ] FEMALE: Premenstrual tension, menstrual ramps (1) BEDALE: Vaginal dlschargs, burning, ching, [1 FEMALE: Endometisis, uterine roids [1 MALE: Prostate problems, impotence. ( ] MALE: Teing of penis or groin. rom xs = (_) kt ‘Rowland Publications ‘Bae Pay Sone ON P24 2 Tato Be «Ps sae « Fx COSTE ls iBrwienpobeom webite wtowaeacom Add up the nuntorsyou have writen beside cach Sttement. Mulply ths total by the factor Inaleoted 1a determine he score for eaoh etn.