Retest Questionnaire On a scale of 0-5, how closely have you been following your Personalized Active Care Plan? 0=not at all, 5=doing well DIET 012345N/A DRY SKIN BRUSHING 012345N/A COFFEE ENEMA 012345N/A MEDITATION 012345N/A SAUNA/SAUNA LIGHT 012345N/A SUPPLEMENTS 012345N/A SLEEP 012345N/A Describe changes you’ve you noticed in your symptoms or condition since you began your Personalized Active Care Plan. Do you have questions about your supplements and detoxification procedures? Is there anything interfering with your ability to follow the program? Is there anything else you want me to know as I update your Personalized Active Care Plan? DIET What are examples of typical breakfasts for you (including beverages)? Mid-morning snacks? What are examples of typical lunches for you (including beverages)? Mid-afternoon snacks? What are examples of typical dinners for you (including beverages)? Evening snacks? HEALTH ISSUES & LIFE EXPERIENCES Symptons / Conditions AcneAddiction – alcoholAddiction – other substancesAddiction – otherAllergies – other than foodAnemiaAngerAnginaAnxietyArteriosclerosisArthritis – osteoArthritis – rheumatoidAsthmaAttention deficit disorderAutismBipolar disorderBladder infectionsBloatingBlood pressure – lowBlood pressure – highBody temperature – lowBrain fogBronchitisBruising – easyBursitisCataractsCholesterol – highCholesterol – poorCirrhosisCold – feeling ofColitisConfusion ConfusionConstipationCoughDepressionDermatitisDevelopment – delayedDiabetesDiarrheaDiverticulitisDizzinessDyslexiaEczemaEmhysemaEyes – glaucomaEyes – macular degenerationFatigueFearFissuresFood – allergiesFood cravings – fatsFood cravings – starchesFood cravings – sweetsFood cravings – otherFood – can't skip mealsFracturesGall stonesGoutHair lossHeadaches – migraineHeadaches – sinusHeadaches – tension Heart attackHeart – atrial fibrillationHeart -palpitationsHeart rate – rapidHeartburnHemorrhoidsHives Hunger – excessiveHunger – little to noneHyperkinesisHyperglycemiaHyperthyroidismHyperglycemiaHyperthyroidismHypoglycemiaHypothyroidsmInfection – bacterialInfection – fungal / candidaInfection – urinary tractInfection – viralInfertilityIntestinal gasIrritabilityIrritability – before mealsJoint painJoint stiffnessKidney infectionsKidney stonesLearning disabilityMemory – poorMeniere's diseaseMind racingMood swings Multiple sclerosisMuscle – crampsMuscle – painMuscle – weaknessNeuritisObsessive / CompulsiveOsteoperosisPanic attacksParkinson's diseasePostnasal dripPsoriasisSchizophreniaSclerodermaSeizuresSinus – congestionSleep – insomniaSleep – disturbanceSmokingStomach painSugar reactionsSuicidal thoughtsTeeth – decayTeeth – dental amalgamsTeeth – excessive plaqueTeeth – gum diseaseTriglycerides – highTumors / CancerUlcerUrination – frequentUrination – painfulVertigoWater rententionWeight – tend to gainWeight – tend to loseWound healing-slow Men: ImpotenceProstate problems Women: Breasts – fibrocysticBreasts – tumorsCrampsFibroid TumorsHot FlashesMenopauseMenstruation – noneMenstruation – heavyMenstruation – irregularMenstruation – lightOvarian cystsPap smear – abnormalPregnant – currentlyPremenstrual syndromeWater retentionYeast infection Comments I have read and accept the Privacy Policy
