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About

Wellness Issues

Please check any symptoms you experience in each section.

* Indicates required field

Name *

First

Last

Email *

System 1: Flow

Kidney & Bladder

Check all that apply: *

Involuntary urination with cough, lifting or strain Low back issues Abdominal discomfort Pain or burning on urination Rarely feel urgency to urinate Urge to urinate is less than every 2 hours Urine smells strong Back or leg pain with dripping after urination Genitals hurt Rose colored urine Sudden urgency causes leaking Systemic water retention

Muscle (& related peripheral nerves - System 4: Communication)

Check any you experience: *

Stiff, sore muscles Burning, shooting, throbbing or stabbing pain in muscles Muscles spasm after use Morning muscle pain and stiffness Tender points on body Unrefreshed by sleep Headache Pain in sides of head on waking Jaw clicks or pops Muscle twitches in eyelid, thumb or calf Restless legs Legs move while sleeping Crawling sensation inside calves when in bed Hand or wrist numbness or pain interfering with writing or buttoning Pins and needles feeling in thumb and first 3 fingers Pain in forearm, and sometimes in shoulder

Please describe your strongest Symptom in System 1: *

How strong is your strongest System 1 symptom? *

1: Minimal 2: Mild 3: Moderate 4: Severe 5: Maximal

Please also complete the section for Male or Female Wellness.

System 2: Support

Heart

Please mark all that apply: *

Jittery Morning chest pain, pressure, heaviness or tightness with first exertion Exhausted by minor effort Profuse sweating (without exertion or hot flashes) Hard to catch breath when exercising Heart pounding (fast, slow or irregular) Intermittent swelling in lower extremeties

Circulation

Mark any issues you experience: *

Muscle pain without exertion Cramping pain in ankle or leg Numbness or tingling in hands and feet Bluish feet or toes from cold Momentary hearing loss Brief bouts of nausea unrelated to eating Legs heavy and tired when standing Leg comfort better with elevation Fingers and toes numb in cold despite protection Change in pain or temperature sensation Loss of body hair on extremeties Decrease in concentration, decision making or ability to follow directions

Bone	Please check all applicable symptoms: * Bones ache Local bone pain Tightness, spasm or numbness in hands, feet or throat Hard to sit straight Upper back pain Lower back pain Pain sitting or walking Limp or favor one leg Shins hurt with exercise

Connective Tissue

Select all that apply: *

Morning stiffness Hard to pick things up off floor Pain, swelling or stiffness of any joints Joint pain with motion or weight bearing Knees swell with exercise Harder to open jars Neck, shoulder or arm pain or numbness Intermittent, spreading pain on one side of head Hard to chew or open mouth Hard to stand when seated Shooting, tingling pain down back of leg Challenge picking up 5 pounds from overhead Easily injured

Respiratory Immunity (including Eyes, Ears, Nose, Throat)

Choose all that apply: *

Eyes water Mucus in eyes Ears hurt, congested or itchy Discharge from ears Nasal congestion Snoring Nose runs Nosebleeds Hoarseness Have to clear throat Lump in throat

Systemic Immunity

Please select all that apply: *

Severe colds Frequent winter colds Flu lasts over 5 days Infections go to lungs Certain foods like dairy or wheat cause eye, ear, nose, throat or lung symptoms Change of seasons affects eye, ear, nose, throat or lung symptoms

Please describe your strongest symptom in System 2: Support *

How strong is your strongest System 2: Support symptom? *

1: Minimal 2: Mild 3: Moderate 4: Strong 5: Maximal

System 3: Process

Respiration

Choose all that apply: *

Chest discomfort Sudden challenges with breath Shortness of breath Hard to exhale Slight exertion causes loss of breath, then coughing Uncomfortable breathing lying down Cough up phlegm Rattling in chest with breathing Coughing Wheezing Night sweats Lips or nails bluish Sleepy during day Hard to concentrate

Stomach (hypo function)

Please mark all symptoms you experience: *

Indigestion or reflux Stomach gas, bloating or burping Stomach cramps Stomach discomfort, pressure or bloating Bad taste or smell in mouth Feel full with small amount of food Skip meals due to lack of appetite

Stomach (hyper function)

Mark all that apply to you: *

Emotion, thought of food, or smell of food aggravate stomach Hungry within 2 hours of solid meal Stomach irritation 1-4 hours after meal Stomach irritation better with food, soda, dairy or antacid Burning above stomach on lying or bending Digestion better with rest or relaxation Stomach irritation with spice, fat, chocolate, coffee, alcohol, or citrus Nausea when eating Issues with swallowing

Pancreas & Small Intestines

Please select your symptoms: *

Tenderness under ribs on left side Abdominal discomfort 2-4 hours after eating Lower bowel discomfort better with release of gas or stool Indigetstion from certain foods or drinks Stool changes through the day Stool smells bad Undigested food visible in stool At least 3 large stools a day Loose stool Pass stool less than 1 hour after meal

Liver, Gall Bladder & Pancreas

Mark your symptoms: *

Tenderness under right lower ribs Deep breath increases abdominal pain Pain in back or right shoulder at night Bitter taste after eating Abdominal pain or nausea after rich or fatty food Forehead pain or throbbing temples from overeating Itchy skin especially at night Stool alternately grey and brown

Liver

Which do you experience? *

Poor general health Muscles ache without exercise Abdominal fluid retention Red palms and skin Strong body odor Embarrassed by breath Bruising Yellow in whites of eyes

Large Intestine

Please mark each issue you experience: *

Colon discomfort Bloating, gas, cramps or pain from raw food or stress Constipation or strain moving bowels Small, hard, dry stool Mucus in stool Alternating hard and soft stool Pain, cramps or itching in rectum Lack of urge to move bowels Frequent need for bowel movement

Please describe your most intense symptom in System 3: Processing *

How strong is your strongest System 3: Processing symptom? *

1: Minimal 2: Mild 3: Moderate 4: Strong 5: Maximal

System 4: Communication

Adrenal (hypo function)

Mark all your symptoms: *

Lasting fatigue after exercise or stress Easily exhausted Crave salt Sensitive to weather and environment Dizzy on rising Dark circles under eyes Nausea (with or without vomiting) Catch colds easily Heal slowly Sensations of tenderness, sensitivity, or heat Feel puffy Skin spontaneously darkening

Sugar Regulation (hypoglycemia)

Select all your symptoms: *

Weakness Anxious when hungry Tingling in hands Heart beats too hard or fast Hands shake or tremble Sudden sweating or clammy skin Nightmares, especially going to bed hungry Restless in middle of the night Get agitated, upset or nervous Memory issues Confusion or disorientation Dizziness or fainting Cold or numbness Headaches Blurry or double vision Clumsiness or poor coordination

Sugar Regulation (hyperglycemia)

Mark all that apply: *

Frequent urination Can’t drink enough Hungry and eating all the time Blurry vision Itchiness Feet tingle or numb Drowsy or lethargic despite eating and sleeping Gain weight on healthy starches Slow healing Loss of leg hair

Thyroid (hypo function)

Check any of these that you notice: *

Get chilled easily Upper eyelids swollen Muscles tremble, cramp or feel weak Memory issues Slow heart beat Slow reaction time Low libido Feel sluggish Constipation Dry, discolored skin or hair Voice deepening Thick nails break easily Easily gain weight Thinning outer third of eyebrow Swelling in neck

Brain

Choose all that apply to you: *

Heavy head Dizziness Challenge with bending, standing, rolling over or turning head Hands tremble for no reason Feeling of weights on feet Clumsiness, tripping, bumping into things Breathing challenges Swallowing challenges People have a hard time hearing you Speaking is an effort Need 10 or more hours sleep to feel rested Lack of strength Writing is tiresome, and handwriting has become smaller and less legible Muscles in limbs have gotten smaller and softer Loss of acuity of eyesight, smell, taste or hearing Moving slower

What is the most intense System 4: Communicate issue for you? *

How intense is your strongest System 4: Communication challenge? *

1: Minimal 2: Mild 3: Moderate 4: Strong 5: Maximum challenge

System 5: Integrity

Skin	Please check all that apply to you: * Itching Redness or blemishes Cracked skin Weeping skin Sagging skin Wrinkles Age spots

What is your strongest System 5: Integrity skin symptom? *

How intense is your strongest System 5: Integrity skin issue? *

1: Minimal 2: Mild 3: Moderate 4: Strong 5: Maximum severity

Be sure to also complete either the Male or Female Wellness questions, as well as the Psychoemotional survey, and then apply for your consultation, energy scan, biofield analysis, coaching and personally formulated one-month wellness makeover program of natural remedies.

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