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Updated 8/29/2009 Glad to see that you are enjoying all the true facts on these different health issues. If you would like to help keep this site up and running, send a donation to:Dr. Bernard Presser, 2632 E. Larkspur Dr., Phoenix, Arizona 85032 We appreciate any help that you can give. Thank You!! If you have any questions, please contact us at 602-651-1546. After reading this valuable information, find a local Chiropractor to order Standard Process Supplements that are Whole Food Nutrition. Standard Process is the only true whole food nutrition that is made up of only organic food that I know of. My wish for you is to be in the best of health possible and I hope this website has helped you in some way. Sample Questionaire Only Health Questionaire FORM (Partial Survey) Patient____________________Date____________________________ Birth Date___/____/_____ Approx Weight______ Vegetarian: YesNo Sex: Male Female INSTRUCTIONS: Fill in only the squares which apply to you. MILD symptoms (occurred once or twice last 6 months). Square 1 MODERATE symptoms (occurred once or twice last month). Square 2 SEVERE symptoms (chronic, occurred once or twice last week). Square 3 Leave Squares BLANK if they don't apply to you!
GROUP 1 1 2 3 1 Acid foods upset 2 Get chilled often 3 "Lump" in throat 4 Dry mouth-eyes-nose 5 Pulse speeds after meal 6 Keyed up - fail to calm 7 Cut heals slowly 8 Gag easily 9 Unable to relax; startles easily 10 Extremities cold, clammy 11 Strong light irritates 12 Urine amount reduced 13 Heart pounds after retiring 14 "Nervous" stomach 15 Appetite reduced 16 Cold sweats often 17 Fever easily raised 18 Neuralgia-like pains 19 Staring blinks little 20 Sour stomach often
GROUP 2 1 2 3 21 Joint stiffness on arising 22 Muscle-leg-toe cramps at night 23 "Butterfly" stomach, cramps 24 Eyes or nose watery 25 Eyes blink often 26 Eyelids swollen, puffy 27 Indigestion soon after meals 28 Always seems hungry; feels "lightheaded" often 29 Digestion rapid 30 Vomiting frequent 31 Hoarseness frequent 32 Breathing irregular 33 Pulse slow; feels "irregular" 34 Gagging reflex slow 35 Difficulty swallowing 36 Constipation, diarrhea alternating 37 "Slow starter" 38 Get "chilled" infrequently 39 Perspire easily 40 Circulation poor, sensitive to cold 41 Subject to colds, asthma, bronchitis
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